Health Demographics of Nepal

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8th Feb 2020 Health Reference this

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1 Introduction

1.1 Background of Nepal

The Federal Democratic Republic of Nepal is small landlocked country in the south Asia bordered by two large countries, India to the east, west and south and China to the north. The total area of the country is 147,181 square kilometers. Topographically, Nepal is divided into three distinct regions, namely mountainous which covers 15%, hilly covering 68% and plain (Terai) covering 17% of the land area. According to world population review 2018, the estimated population is 29.5 million. The population growth rate is 1.35% annually and the total fertility rate is 2.3 per woman according to Nepal Demographic Health Survey (NDHS) 2016 (‘Nepal demographic and health survey 2016,’ 2017). An estimated 9.18% of the population is under the age of five (CBS 2011).

Nepal is one of the low-income countries in the world with a low Human Development Index (HDI) value of 0.574 and in 149th position in HDI rank out of 189 countries according to the Human Development Reports UNDP 2018.

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Nepal is a multicultural country with variety of religions, castes and languages. More than 80% of the population is Hindu and remaining are Buddhist, Muslim, Kirat, Christian and others. According to the 2011 census, there are 126 castes in Nepal. The caste system is deeply rooted in Hindu religion (CBS 2011)

The literacy rate of Nepali people is 65.9%, varying from 86.3% in the capital, Kathmandu, to 47.8% in the remote district of Humla. The male literacy rate, at 74.1%, is much higher than the female rate, at which is 57.4% National Population and Housing Census (NPHC), 2011

1.2  Newborn Health

A newborn infant or neonate is a child under 28 days of age. The neonatal mortality rate (NMR) is the number of live birth babies who die in the first 28 days after birth per 1,000 live births (WHO 2009). Children face the highest risk of dying in their first month of life at an average global rate of 18 deaths per 1,000 live births in 2017. Comparatively, the probability of dying after the first month but before reaching age 1 was 12 and after age 1 but before age 5 was 10. Globally, 2.5 million children died in the first month of life in 2017 alone – 7000 neonatal deaths every day – most of which occurred in the first week, with about 1 million dying on the first day and close to 1 million dying within the next six days. (United Nations Inter-Agency Group for Child Mortality Estimation, 2018)

Nepal was able to achieve the Millennium Development (MDG) Goal 4 by reducing the under-five mortality rate by two thirds from the level in 1990 in spite of high poverty, poor infrastructure, diverse topography, conflict and political instability. The mortality indicators like neonatal, infant and under- five are very important indicators to reflect the progress in health status as well as overall socioeconomic development of a country. In Nepal, approximately 35,000 under five children die every year, with almost two third of these deaths occurring in the neonatal period (Y. Pradhan et. al 2012).

1.3 Trends of neonatal mortality Nepal

According to the Nepal Demographic Health Survey (NDHS) 2016, the neonatal mortality rate is 21/1000 live births. The under-five child mortality rate fell over 20 years (from 1996 to 2016) from 118 to 39 per 1,000 live births. Infant mortality declined by 58% (from 78 to 32 per 1,000 live births) over the same period. Neonatal mortality is also decreased by 58% (21 from 50/1,000 live births) in this period and so shows that 54% of all under 5 deaths occur in the first month of life. Early neonatal deaths (0-6 days) account for more than three quarters, i.e. 79% of the total neonatal deaths. A report on verbal autopsy to ascertain causes of Neonatal Deaths in Nepal, 2014 shows that the major cause of neonatal mortality is neonatal sepsis, birth asphyxia and prematurity related. Similarly, the mortality due to birth asphyxia observed to be high on the day of birth and deaths due to neonatal sepsis found to be particularly high on the third day of birth.

Figure 1: Trends in early childhood mortality

The decreasing childhood mortality rates has increased the burden of neonatal deaths. The Nepal Health Sector Strategy (2016-2021) have set a target to reduce neonatal mortality to 17.5 live births by the end of the year 2021 (NHSS 2016). Similarly, the Sustainable Development Goals targets to reduce the neonatal mortality rate 12 per 1000 live births by 2030. This target cannot be achieved until and unless the maternal health indicators are improved. Having four Antenatal Care (ANC) visits or the childbirth assisted by a skilled birth attendant (SBA) halves the risk of neonatal mortality, though utilization of such services is unequal among high-risk and disadvantaged groups of women. (Trends and Determinants of Neonatal Mortality in Nepal Further Analysis of the Nepal Demographic and Health Surveys, 2001-2011)

Figure 2: Trend of Maternal Health Indicator

  1. Causes of neonatal mortality

The leading causes of neonatal death in Nepal are respiratory and cardiovascular disorders of the perinatal period (30%) and complications of pregnancy, labor, and delivery (31%) (Figure 2). These are followed by neonatal deaths from infection specific to perinatal period (16%), congenital malformations and deformations (7%), hypothermia (4%) and disorders related to length of gestation and fetal growth account for 2% of neonatal deaths. Sudden neonatal deaths account for 6% of total deaths. (NDHS, 2016)

Figure 3: Causes of neonatal death

  1. Newborn Health Disparities

The underlying causes of high neonatal mortality in Nepal is largely due to the higher rates of NMR among poor socio-economic groups, Muslims and Dalits, as well as people living in remote areas (Resham Bahadur et al., 2016). Neonatal mortality rate is 26 per 1,000 live births in rural areas, as compared with 16 per 1,000 live births in urban areas. (NDHS 2016). NMR among the poorest households is 36 neonatal deaths per 1000 live births, compared to 12 deaths per 1,000 live births among the richest wealth quintile. Yaliso Yaya, Kristiane Tislevoll Eide, Ole Frithjof Norheim, and Bernt Lindtjørn also concluded from the study that neonatal mortality is 2.6 times higher among poor wealth quintile compared to rich one in Bonke, South Ethiopia. (Yaya Y., et al, 2014). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4005746/

Newborns of illiterate mothers were twice as likely to suffer neonatal death than those born to women with higher levels of education. Similarly, neonatal mortality ranges from a low of 15 deaths per 1,000 live births in Province 4 to a high of 41 in Province 7. Mother’s age also plays a role. In NDHS 2016, neonatal mortality was 39 deaths per 1,000 live births among those born to younger mothers (<20 years) compared with 21 deaths per 1,000 live births among mothers age 20-29.

Table 1: Socio economic factors for neonatal mortality

Characteristics

Neonatal Mortality

% receiving 4 Antenatal Care

% delivered in a health facility

% delivered by a skilled provider

% of births with a PNC check during the first 2 days after birth

Mother’s age at birth

<20

39

55.8

63.7

64.4

60.7

20-29

21

60.1

56.3

57

56.5

30-39

31

49.4

41.2

41.5

39.0

Residence

Urban

 24

64.8

68.6

67.7

63.4

Rural

 16

51.0

44.2

46.8

49.1

Ecological Zone

Mountain

35

58.9

41.7

43.3

49.2

Hill

23

68.3

61

60.9

62.6

Terai

28

51.8

56.9

58

53.6

Province

Province 1

22

62.6

62.2

63.1

60.1

Province 2

30

36.1

44.6

48.6

46.2

Province 3

17

70.7

70.7

69.6

66.7

Province 4

15

66.5

68.3

69.6

65.7

Province 5

30

67.3

59.4

56.6

59.9

Province 6

29

47.3

35.6

35.3

40.7

Province 7

41

73.0

66.4

66

59.6

Mother’s Education

No education

36

41.5

36.4

37.6

41.9

Primary

25

53.0

49.2

50.2

48.0

Some Secondary

20

64.6

69.1

69.7

62.7

Grade 10&above

12

77.5

85.4

84.9

75.4

Wealth quintile

Lowest

36

52.1

33.9

33.9

42.2

Second

33

53.5

46.6

48

50.4

Middle

26

51.7

57.6

59.4

54.9

Fourth

20

61.2

69.5

70

68.2

Highest

12

79.2

89.6

88.7

73.8

Total

21

58.8

57.4

58

56.8

 

Initiatives to improve neonatal health in Nepal

Nepal government, Ministry of Health and Population has endorsed several initiatives to improve neonatal health in Nepal. The key newborn initiatives with political priority are presented in the table below.

Year

Program

Newborn survival interventions

1997- Piloted

2009- Nationwide

Community Based Integrated Management of Childhood Illness (CB IMCI)

•         Early identification of newborn illness

•         Community-based management and referral of sick newborns

2000

Millennium Development Goal (MDG)

The United Nations (UN) Millennium Declaration was adopted by countries around the world including Nepal with the common goal of reducing under-five child mortality by two thirds by 2015.

2001

Saving Newborn Lives (SNL) program

The Government of Nepal (GoN) implemented Saving Newborn Lives (SNL) with support of Save The Children and further prepared a comprehensive report regarding problems related to newborn survival in Nepal. This was launched by the Prime Minister declaring the problem of newborn survival and given high priority.

2003- Piloted

2008- Nationwide

Birth preparedness package (BPP)

Education and Counselling on:

•         Preparedness for safe delivery and promoting essential newborn care practices (clean cord, wiping, wrapping, immediate breastfeeding and delayed bathing)

•         Danger signs during pregnancy, delivery and the postnatal period

•         Danger signs among newborns

•         Tetanus toxoid vaccination

2004

First National Neonatal Health Strategy

Goal

•         Improve the health and survival of newborn babies in Nepal

Objectives

•         To promote healthy newborn practices, discourage prevailing harmful practices and to strengthen promotive, preventive and curative neonatal services at all levels of the health system

2005- Piloted

2008- Nationwide

Maternity Incentives Program (Aama Surakchya Program)

It provides cash to women giving birth in a health facility and an incentive to the health provider for each delivery attended, either at home or in the facility.

•         Promotion of institutional delivery and/or home delivery by skilled birth attendant

•         Care for immediate newborn problems (e.g. birth asphyxia)

2007

Umbilical cord care for newborns (CHX cord care)

•         Use of chlorohexidine for prevention of umbilical cord infections

2009

Community-based Newborn Care Package (CB NCP)

•         Promotion of institutional delivery and clean delivery practices at home

•         Postnatal care

•         Community-based case management of pneumonia and severe bacterial infections

•         Care for low birth weight newborns

•         Prevention and management

of hypothermia

•         Recognition of asphyxia

•         Initial stimulation and resuscitation of newborns

2014

Nyano Jhola (Warm Bag) program

The bag consists of clothes including gloves, socks, cap, napkin, and diaper for the newborn and a gown for the mother.

The main objective of this initiative is to reduce neonatal death due to hypothermia and encourage mother to use institutional delivery.

2015

Nepal’s Every Newborn Action Plan (NENAP)

The NENAP aims to achieve a newborn mortality rate (NMR) of less than 11 deaths per 1000 live births by 2035 in all provinces of Nepal

References

1 Introduction

1.1 Background of Nepal

The Federal Democratic Republic of Nepal is small landlocked country in the south Asia bordered by two large countries, India to the east, west and south and China to the north. The total area of the country is 147,181 square kilometers. Topographically, Nepal is divided into three distinct regions, namely mountainous which covers 15%, hilly covering 68% and plain (Terai) covering 17% of the land area. According to world population review 2018, the estimated population is 29.5 million. The population growth rate is 1.35% annually and the total fertility rate is 2.3 per woman according to Nepal Demographic Health Survey (NDHS) 2016 (‘Nepal demographic and health survey 2016,’ 2017). An estimated 9.18% of the population is under the age of five (CBS 2011).

Nepal is one of the low-income countries in the world with a low Human Development Index (HDI) value of 0.574 and in 149th position in HDI rank out of 189 countries according to the Human Development Reports UNDP 2018.

Nepal is a multicultural country with variety of religions, castes and languages. More than 80% of the population is Hindu and remaining are Buddhist, Muslim, Kirat, Christian and others. According to the 2011 census, there are 126 castes in Nepal. The caste system is deeply rooted in Hindu religion (CBS 2011)

The literacy rate of Nepali people is 65.9%, varying from 86.3% in the capital, Kathmandu, to 47.8% in the remote district of Humla. The male literacy rate, at 74.1%, is much higher than the female rate, at which is 57.4% National Population and Housing Census (NPHC), 2011

1.2  Newborn Health

A newborn infant or neonate is a child under 28 days of age. The neonatal mortality rate (NMR) is the number of live birth babies who die in the first 28 days after birth per 1,000 live births (WHO 2009). Children face the highest risk of dying in their first month of life at an average global rate of 18 deaths per 1,000 live births in 2017. Comparatively, the probability of dying after the first month but before reaching age 1 was 12 and after age 1 but before age 5 was 10. Globally, 2.5 million children died in the first month of life in 2017 alone – 7000 neonatal deaths every day – most of which occurred in the first week, with about 1 million dying on the first day and close to 1 million dying within the next six days. (United Nations Inter-Agency Group for Child Mortality Estimation, 2018)

Nepal was able to achieve the Millennium Development (MDG) Goal 4 by reducing the under-five mortality rate by two thirds from the level in 1990 in spite of high poverty, poor infrastructure, diverse topography, conflict and political instability. The mortality indicators like neonatal, infant and under- five are very important indicators to reflect the progress in health status as well as overall socioeconomic development of a country. In Nepal, approximately 35,000 under five children die every year, with almost two third of these deaths occurring in the neonatal period (Y. Pradhan et. al 2012).

1.3 Trends of neonatal mortality Nepal

According to the Nepal Demographic Health Survey (NDHS) 2016, the neonatal mortality rate is 21/1000 live births. The under-five child mortality rate fell over 20 years (from 1996 to 2016) from 118 to 39 per 1,000 live births. Infant mortality declined by 58% (from 78 to 32 per 1,000 live births) over the same period. Neonatal mortality is also decreased by 58% (21 from 50/1,000 live births) in this period and so shows that 54% of all under 5 deaths occur in the first month of life. Early neonatal deaths (0-6 days) account for more than three quarters, i.e. 79% of the total neonatal deaths. A report on verbal autopsy to ascertain causes of Neonatal Deaths in Nepal, 2014 shows that the major cause of neonatal mortality is neonatal sepsis, birth asphyxia and prematurity related. Similarly, the mortality due to birth asphyxia observed to be high on the day of birth and deaths due to neonatal sepsis found to be particularly high on the third day of birth.

Figure 1: Trends in early childhood mortality

The decreasing childhood mortality rates has increased the burden of neonatal deaths. The Nepal Health Sector Strategy (2016-2021) have set a target to reduce neonatal mortality to 17.5 live births by the end of the year 2021 (NHSS 2016). Similarly, the Sustainable Development Goals targets to reduce the neonatal mortality rate 12 per 1000 live births by 2030. This target cannot be achieved until and unless the maternal health indicators are improved. Having four Antenatal Care (ANC) visits or the childbirth assisted by a skilled birth attendant (SBA) halves the risk of neonatal mortality, though utilization of such services is unequal among high-risk and disadvantaged groups of women. (Trends and Determinants of Neonatal Mortality in Nepal Further Analysis of the Nepal Demographic and Health Surveys, 2001-2011)

Figure 2: Trend of Maternal Health Indicator

  1. Causes of neonatal mortality

The leading causes of neonatal death in Nepal are respiratory and cardiovascular disorders of the perinatal period (30%) and complications of pregnancy, labor, and delivery (31%) (Figure 2). These are followed by neonatal deaths from infection specific to perinatal period (16%), congenital malformations and deformations (7%), hypothermia (4%) and disorders related to length of gestation and fetal growth account for 2% of neonatal deaths. Sudden neonatal deaths account for 6% of total deaths. (NDHS, 2016)

Figure 3: Causes of neonatal death

  1. Newborn Health Disparities

The underlying causes of high neonatal mortality in Nepal is largely due to the higher rates of NMR among poor socio-economic groups, Muslims and Dalits, as well as people living in remote areas (Resham Bahadur et al., 2016). Neonatal mortality rate is 26 per 1,000 live births in rural areas, as compared with 16 per 1,000 live births in urban areas. (NDHS 2016). NMR among the poorest households is 36 neonatal deaths per 1000 live births, compared to 12 deaths per 1,000 live births among the richest wealth quintile. Yaliso Yaya, Kristiane Tislevoll Eide, Ole Frithjof Norheim, and Bernt Lindtjørn also concluded from the study that neonatal mortality is 2.6 times higher among poor wealth quintile compared to rich one in Bonke, South Ethiopia. (Yaya Y., et al, 2014). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4005746/

Newborns of illiterate mothers were twice as likely to suffer neonatal death than those born to women with higher levels of education. Similarly, neonatal mortality ranges from a low of 15 deaths per 1,000 live births in Province 4 to a high of 41 in Province 7. Mother’s age also plays a role. In NDHS 2016, neonatal mortality was 39 deaths per 1,000 live births among those born to younger mothers (<20 years) compared with 21 deaths per 1,000 live births among mothers age 20-29.

Table 1: Socio economic factors for neonatal mortality

Characteristics

Neonatal Mortality

% receiving 4 Antenatal Care

% delivered in a health facility

% delivered by a skilled provider

% of births with a PNC check during the first 2 days after birth

Mother’s age at birth

<20

39

55.8

63.7

64.4

60.7

20-29

21

60.1

56.3

57

56.5

30-39

31

49.4

41.2

41.5

39.0

Residence

Urban

 24

64.8

68.6

67.7

63.4

Rural

 16

51.0

44.2

46.8

49.1

Ecological Zone

Mountain

35

58.9

41.7

43.3

49.2

Hill

23

68.3

61

60.9

62.6

Terai

28

51.8

56.9

58

53.6

Province

Province 1

22

62.6

62.2

63.1

60.1

Province 2

30

36.1

44.6

48.6

46.2

Province 3

17

70.7

70.7

69.6

66.7

Province 4

15

66.5

68.3

69.6

65.7

Province 5

30

67.3

59.4

56.6

59.9

Province 6

29

47.3

35.6

35.3

40.7

Province 7

41

73.0

66.4

66

59.6

Mother’s Education

No education

36

41.5

36.4

37.6

41.9

Primary

25

53.0

49.2

50.2

48.0

Some Secondary

20

64.6

69.1

69.7

62.7

Grade 10&above

12

77.5

85.4

84.9

75.4

Wealth quintile

Lowest

36

52.1

33.9

33.9

42.2

Second

33

53.5

46.6

48

50.4

Middle

26

51.7

57.6

59.4

54.9

Fourth

20

61.2

69.5

70

68.2

Highest

12

79.2

89.6

88.7

73.8

Total

21

58.8

57.4

58

56.8

 

Initiatives to improve neonatal health in Nepal

Nepal government, Ministry of Health and Population has endorsed several initiatives to improve neonatal health in Nepal. The key newborn initiatives with political priority are presented in the table below.

Year

Program

Newborn survival interventions

1997- Piloted

2009- Nationwide

Community Based Integrated Management of Childhood Illness (CB IMCI)

•         Early identification of newborn illness

•         Community-based management and referral of sick newborns

2000

Millennium Development Goal (MDG)

The United Nations (UN) Millennium Declaration was adopted by countries around the world including Nepal with the common goal of reducing under-five child mortality by two thirds by 2015.

2001

Saving Newborn Lives (SNL) program

The Government of Nepal (GoN) implemented Saving Newborn Lives (SNL) with support of Save The Children and further prepared a comprehensive report regarding problems related to newborn survival in Nepal. This was launched by the Prime Minister declaring the problem of newborn survival and given high priority.

2003- Piloted

2008- Nationwide

Birth preparedness package (BPP)

Education and Counselling on:

•         Preparedness for safe delivery and promoting essential newborn care practices (clean cord, wiping, wrapping, immediate breastfeeding and delayed bathing)

•         Danger signs during pregnancy, delivery and the postnatal period

•         Danger signs among newborns

•         Tetanus toxoid vaccination

2004

First National Neonatal Health Strategy

Goal

•         Improve the health and survival of newborn babies in Nepal

Objectives

•         To promote healthy newborn practices, discourage prevailing harmful practices and to strengthen promotive, preventive and curative neonatal services at all levels of the health system

2005- Piloted

2008- Nationwide

Maternity Incentives Program (Aama Surakchya Program)

It provides cash to women giving birth in a health facility and an incentive to the health provider for each delivery attended, either at home or in the facility.

•         Promotion of institutional delivery and/or home delivery by skilled birth attendant

•         Care for immediate newborn problems (e.g. birth asphyxia)

2007

Umbilical cord care for newborns (CHX cord care)

•         Use of chlorohexidine for prevention of umbilical cord infections

2009

Community-based Newborn Care Package (CB NCP)

•         Promotion of institutional delivery and clean delivery practices at home

•         Postnatal care

•         Community-based case management of pneumonia and severe bacterial infections

•         Care for low birth weight newborns

•         Prevention and management

of hypothermia

•         Recognition of asphyxia

•         Initial stimulation and resuscitation of newborns

2014

Nyano Jhola (Warm Bag) program

The bag consists of clothes including gloves, socks, cap, napkin, and diaper for the newborn and a gown for the mother.

The main objective of this initiative is to reduce neonatal death due to hypothermia and encourage mother to use institutional delivery.

2015

Nepal’s Every Newborn Action Plan (NENAP)

The NENAP aims to achieve a newborn mortality rate (NMR) of less than 11 deaths per 1000 live births by 2035 in all provinces of Nepal

References

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