BETTER CORD CARE SAVES BABIES LIVES

Leela Khanal, Project Director, JSI Chlorhexidine Navi (Cord) Care Program February 13, 2015

Nepalese Context of Delivery and Cord Care

45% deliveries occurred at home (Source: MICS 2014)

Among the home deliveries, 82 % used a clean delivery kit or new/boiled blade (Source: NDHS 2011)

Child birth considered an impure and dirty process

Among the home deliveries, 41% of newborns had material on stump (Source: NDHS

2011)

Around 40 newborns die per day in Nepal

Source: MICS 2014

Source: Verbal autopsy to ascertain causes of neonatal deaths in Nepal, 2014

Sepsis is the leading cause of neonatal deaths in Nepal

Source: * NDHS, ** MICS

118

91

61 54

38

79

64

48 46

33

50

39 33 33

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20

40

60

80

100

120

140

1996* 2001* 2006* 2011* 2014**

Pe

r 1

00

0 li

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irth

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Trend of Under-5 Mortality Rates in Nepal

U5MR IMR NMR

In Nepal, a groundbreaking program has prevented at least 3,900 newborn deaths

Winner 2013

USAID

Pioneers Prize

in Science and

Technology

Project name: Chlorhexidine Navi (Cord) Care Program Program Period: 2011-2017 Principal Donors: USAID, the Government of Norway, Bill & Melinda Gates Foundation, Grand Challenges Canada and Department for International Development Partners: Ministry of Health and Population, PLAN, SAVE, UNICEF, CARE, OHW, Lomus Pharmaceuticals

Addressing a problem with high

population health burden

Efficacy & low cost

Simplicity, acceptability & safety

Low regulatory requirements

Health system compatibility &

scalability

Why Nepal accepted Chlorhexidine (CHX) cord care

First evidence was from Nepal (Source: JHU/NNIPS RCT, 2006)

CHX in Nepal: A timeline 2002-5 Initial

efficacy research in

Sarlahi

2008-9 Lomus begins

CHX Production

2006 Sarlahi trials show 34%

reduction in neonatal mortality

2014 Scale up to 49

districts, included CHX in ANM

curriculum, HMIS and CBIMNCI

2017 Goal: Scale

up at national

level

2011 Government

approved and included CHX in essential

drug list

2005-7 Technical Advisory group on

CHX

2008-9 JSI conducted efficacy and community

acceptability study on liquid

vs. gel

2011 Regional

conference held in Nepal, JSI lead piloting in three

districts

2013 JSI/CNCP won The USAID

Pioneers Prize

CHX Implementation Modalities in Nepal

CHX is now available to prevent newborn sepsis at both

facility and home deliveries integrating with on-going

government programs.

9

Central Region

Eastern Region

Mid-Western Region

Far-Western Region

Western Region

Humla

Darchula

Baitadi

Dadeldhura

Kanchanpur

Kailali

Doti

Bajhang

Achham

Mugu

Mustang

Manang

Rasuwa

Kalikot

Dailekh

Surkhet

Jumla

Jajarkot

Banke

Rukum

Salyan

Rolpa

Pyuthan

Myagdi

Baglung

Gulmi

Kapilvastu

Arghakhanc

hi

Kaski

Syangha

Rupandehi

Palpa

Lamjung

Tanahu

Gorkha

Chitwan

Dhading

Nuwakot

Makwanpur

Nawalparasi

Pars

a

Bara

Rau

tah

at*

Taplejung

Solukhumbu Sankhuwasava

Sindhupalchowk

Sarl

ah

i

Dh

an

ush

a

Siraha

Saptari

Sindhuli

Kavre

Dolakha

Ramechhap

Okhaldhunga

Udayapur

Morang Jhapa

Ilam

Khotang Bhojpur

Dhankuta

K

L

B

N

Mah

ott

ari

Dang

45 scaled up districts

4 pilot districts

Implementation status

CHX program: 49/75districts

11

12

Enabling Factors

1. The involvement of government and implementing partners from initial phase

2. The utilization of existing public health delivery systems to implement

3. The integration with on-going health programs at the health facility and community level

13

Enabling Factors continued

4. The integration of CHX in pre-service and in-service curricula

5. The logistics supply mechanism through the existing government system

6. Ensuring the sustainability through the government ownership of the program (included in the multi-year Procurement plan, HMIS, essential drug list, etc.)

14

Challenges • Maintaining high coverage at scale

• Assuring the quality of the CHX product by

different pharmaceutical companies

• Assuring the quality of routine information

systems

• Ensuring timely supply of CHX

• WHO cord care guidelines need updating

Next Steps 1. Expansion at the national level

2. Continue efforts to ensure the quality of the program

3. Integrate CHX in national health policy documents

4. Include CHX in logistics information system, free drug

list, in-service and pre-service curricula

5. Strengthen routine health information systems

6. Support for uninterrupted supply of CHX

Based on the experience of the Nepal CHX program, we recommend:

• Ensuring government leadership from the start

• Planning integration from the start

• Joining existing networks

• Adding CHX to the essential medicines list

• Leveraging resources from other countries and programs

• Ensuring funding commitments for sustainability

Conclusions • CHX application saves newborn lives

• CHX is safe, acceptable and low-cost

• Harmful cord care practices can be replaced

• Mother or family members can easily apply

• Easy to distribute to pregnant women through community-

based volunteers and antenatal clinics included in the public

health service delivery system

• Other countries with similar conditions should consider CHX to

save newborn lives