BackgroundThe Every Newborn Action Plan (ENAP), launched in 2014, aims to end preventable newborn deaths and stillbirths, with national targets of ≤12 neonatal deaths per 1000 live births and ≤12 stillbirths per 1000 total births by 2030. This requires ambitious improvement of the data on care at birth and of small and sick newborns, particularly to track coverage, quality and equity.MethodsIn a multistage process, a matrix of 70 indicators were assessed by the Every Newborn steering group. Indicators were graded based on their availability and importance to ENAP, resulting in 10 core and 10 additional indicators. A consultation process was undertaken to assess the status of each ENAP core indicator definition, data availability and measurement feasibility. Coverage indicators for the specific ENAP treatment interventions were assigned task teams and given priority as they were identified as requiring the most technical work. Consultations were held throughout.ResultsENAP published 10 core indicators plus 10 additional indicators. Three core impact indicators (neonatal mortality rate, maternal mortality ratio, stillbirth rate) are well defined, with future efforts needed to focus on improving data quantity and quality. Three core indicators on coverage of care for all mothers and newborns (intrapartum/skilled birth attendance, early postnatal care, essential newborn care) have defined contact points, but gaps exist in measuring content and quality of the interventions. Four core (antenatal corticosteroids, neonatal resuscitation, treatment of serious neonatal infections, kangaroo mother care) and one additional coverage indicator for newborns at risk or with complications (chlorhexidine cord cleansing) lack indicator definitions or data, especially for denominators (population in need). To address these gaps, feasible coverage indicator definitions are presented for validity testing. Measurable process indicators to help monitor health service readiness are also presented. A major measurement gap exists to monitor care of small and sick babies, yet signal functions could be tracked similarly to emergency obstetric care.ConclusionsThe ENAP Measurement Improvement Roadmap (2015-2020) outlines tools to be developed (e.g., improved birth and death registration, audit, and minimum perinatal dataset) and actions to test, validate and institutionalise proposed coverage indicators. The roadmap presents a unique opportunity to strengthen routine health information systems, crosslinking these data with civil registration and vital statistics and population-based surveys. Real measurement change requires intentional transfer of leadership to countries with the greatest disease burden and will be achieved by working with centres of excellence and existing networks.

Problem Pneumonia is a leading cause of mortality of children aged under five in Nepal. Research conducted by John Snow Inc. in the 1980s determined that pneumonia case management by community-based workers decreased under-five mortality by 28%. Approach Female community health volunteers were selected as the national cadre to manage childhood pneumonia at community level using oral antibiotics. A technical working group composed of government officials, local experts and donor partners embarked on a process to develop a strategy to pilot the approach and expand it nationally. Local setting High under-five mortality rates, low access to peripheral health facilities and severe constraints in human resources led Nepal's Ministry of Health to test this innovative approach. Relevant changes Community-based management of pneumonia doubled the total number of cases treated compared with districts with facility-based treatment only. Over half of the cases were treated by the female community health volunteers. The programme was phased in over 14 years and now 69% of Nepal's under-five population has access to pneumonia treatment. Lessons learned Community-based management of pneumonia provides a medium-term solution to address a leading cause of child mortality while the efforts continue to strengthen and extend the reach of facility-based care. Trained community health workers can significantly increase the number of pneumonia cases receiving correct case management in resource-constrained settings, with appropriate health systems' support for logistics, supervision and monitoring. Community-based management of pneumonia can be scaled up and provides an effective approach to reducing child deaths in countries faced with insufficient human resources for health.

The mortality rates of infants and children aged less than five years are declining globally and in Nepal but less among neonates. Most deliveries occur at home without skilled attendants, and most neonates may not receive appropriate care through the existing medical systems. So, a community-based pilot programme—Morang Innovative Neonatal Intervention (MINI) programme—was implemented in Morang district of Nepal to see the feasibility of bringing the management of sick neonates closer to home. The objective of this model was to answer the question: “Can a team of female community health volunteers and paid facility-based community health workers (collectively called CHWs) within the existing heath system correctly follow a set of guidelines to identify possible severe bacterial infection in neonates and young infants and successfully deliver their treatment?” In the MINI model, the CHWs followed an algorithm to classify sick young infants with possible severe bacterial infection (PSBI). Female Community Health Volunteers (FCHVS) were trained to visit homes soon after delivery, record the birth, counsel mothers onessential newborn care, and assess the newborns for danger-signs. Infants classified as having PSBI, during this or subsequent contacts, were treated with co-trimoxazole and referred to facility-based CHWs for seven-day treatment with injection gentamicin. Additional supervisory support was provided for quality of care and intensified monitoring. Of 11,457 livebirths recorded during May 2005–April 2007, 1,526 (13.3%) episodes of PSBI were identified in young infants. Assessment of signs by the FCHVs matched that of more highly-trained facility-based CHWs in over 90% of episodes. Treatment was initiated in 90% of the PSBI episodes; 93% completed a full course of gentamicin. Case fatality in those who received treatment with gentamicin was 1.5% [95% confidence interval (CI) 1.0-2.3] compared to 5.3% (95% CI 2.6-9.7) in episodes that did not receive any treatment. Within the existing government health infrastructure, the CHWs can assess and identify possible infections in neonates and young infants and deliver appropriate treatment with antibiotics. This will result in improvement in the likelihood of survival and address one of the main causes of neonatal mortality.

BackgroundThere has been little success in attempts to reduce the proportion of births with low birth weight (LBW). However, deaths associated with LBW may be prevented with extra attention to warmth, feeding, and prevention or early treatment of infections. There are few studies on this in Nepal and in many other developing countries. This is a cohort study to evaluate the risk of deaths among LBW infants who received FCHV follow up visit for home-based care compared to those who did not receive in Rural Nepal.MethodsA cohort study design was used with data from the Morang Innovative Neonatal Intervention (MINI) program in Nepal. Relative Risk (RR) is calculated to compare LBW neonates who received FCHV follow up visit as compared to LBW neonates who did not receive visit.ResultsOut of 51,853 newborn infants recorded in the MINI database, 2229 LBW neonates were included in the analysis. The proportion of deaths among those who received FCHV follow up visit and those who did not receive were 2% (95% CI: 1%; 2%) and 11% (95% CI: 6%; 18%) respectively(P < 0.001). The relative risk of death in LBW infants who received FCHV follow up visit was 84% less as compared to LBW infants who did not receive (RR = 0·16; 95% CI: 0·09, 0·29).ConclusionThe current study indicates that to save the lives of LBW young infants simple home-based measures implemented through trained health volunteers within the existing government health system may be effective when technically more sophisticated measures such as tertiary health centers, pediatricians, and expensive technology are limited.

Introduction: Clinical registration of the cause of death is available for less than one-third of the global newborn deaths, but the need for good quality data on causes of death for public health planning has renewed the interest in the Verbal Autopsy (VA). We aimed to determine the cause of neonatal deaths by VA in Morang district of Nepal. Methods: Caretakers of the deceased were interviewed using a semi-structured VA questionnaire by female community health volunteers. The cause of death was assigned by two senior pediatricians independently and disagreements in ascertaining the proximate cause of death were resolved by consensus. Results: The proximate causes of deaths were infections (41 %), birth asphyxia (37.2 %), prematurity (11.5 %), and low birth weight related causes (6.9 %). There was no signifi cant statistical difference in deaths due to infection seen in non-institutional deliveries (43.5 %) than institutional deliveries (34.6 %). More than half of the deaths (58.5 %) occurred within the fi rst three days of life where the predominant cause of death was birth asphyxia (60.7 %). Conclusions: Analysis of verbal autopsies demonstrates that the major causes of death still are infections and birth asphyxia. The timing of deaths suggests that neonatal interventions should be aimed at the fi rst week of life. There is no comparative advantage between institutional deliveries at below district level institutions and non-institutional deliveries to prevent neonatal infection. Thus, further study on the quality of care at institutes below the district level should be conducted. Disparities still occur in deaths, with most deaths in Morang occurring in non-institutional deliveries and in disadvantaged groups. Keywords: neonatal deaths, Nepal, newborn, verbal autopsy.