Causes and age of neonatal death and associations with maternal and newborn care characteristics in Nepal: a verbal autopsy study

Daniel J Erchick,Luke C Mullany,Nitin N Bhandari,Joanne Katz,Sirjana Khanal,Purusotam R Shedain,Johanna B Lackner,Jyoti R Dhakwa

doi:10.1186/s13690-021-00771-5

Abstract

BackgroundIn Nepal, neonatal mortality fell substantially between 2000 and 2018, decreasing 50% from 40 to 20 deaths per 1,000 live births. Nepal’s success has been attributed to a decreasing total fertility rate, improvements in female education, increases in coverage of skilled care at birth, and community-based child survival interventions.MethodsA verbal autopsy study, led by the Integrated Rural Health Development Training Centre (IRHDTC), conducted interviews for 338 neonatal deaths across six districts in Nepal between April 2012 and April 2013. We conducted a secondary analysis of verbal autopsy data to understand how cause and age of neonatal death are related to health behaviors, care seeking practices, and coverage of essential services in Nepal.ResultsSepsis was the leading cause of neonatal death (n=159/338, 47.0%), followed by birth asphyxia (n=56/338, 16.6%), preterm birth (n=45/338, 13.3%), and low birth weight (n=17/338, 5.0%). Neonatal deaths occurred primarily on the first day of life (27.2%) and between days 1 and 6 (64.8%) of life. Risk of death due birth asphyxia relative to sepsis was higher among mothers who were nulligravida, had <4 antenatal care visits, and had a multiple birth; risk of death due to prematurity relative to sepsis was lower for women who made ≥1 delivery preparation and higher for women with a multiple birth.ConclusionsOur findings suggest cause and age of death distributions typically associated with high mortality settings. Increased coverage of preventive antenatal care interventions and counseling are critically needed. Delays in care seeking for newborn illness and quality of care around the time of delivery and for sick newborns are important points of intervention with potential to reduce deaths, particularly for birth asphyxia and sepsis, which remain common in this population.

Highlights

In Nepal, neonatal mortality fell substantially between 2000 and 2018, decreasing 50% from 40 to 20 deaths per 1,000 live births
Statistical analysis In this secondary analysis, we explored relationships between cause of neonatal death and age of death and risk factors among a sample of live born newborns who died within 28 days of life
Associations between age of newborn death and risk factors were displayed in Kaplan-Meier graphs and evaluated using log-rank tests

Summary

Introduction

In Nepal, neonatal mortality fell substantially between 2000 and 2018, decreasing 50% from 40 to 20 deaths per 1,000 live births. Nepal’s success has been attributed to a decreasing total fertility rate, improvements in female education, increases in coverage of skilled care at birth, and community-based child survival interventions [2, 3]. Achieving the Sustainable Development Goal (SDG) target of reducing neonatal mortality to 12 deaths per 1000 live births by 2030 will require an understanding, across the varied geographical regions in Nepal, of the causes of neonatal death, coverage of critical interventions for newborn survival, newborn care practices, and care seeking behaviors during newborn illness [4]. In 2007, Nepal’s Ministry of Health and Population (MoHP), guided by the National Neonatal Health Strategy 2004, developed the Community-Based Newborn Care Package (CB-NCP), a program aimed to deliver evidence-based health interventions targeting leading causes of neonatal mortality [5,6,7]. After the program was piloted in ten districts (2009– 2010), it was scaled up across Nepal, and eventually merged with the Community-Based Integrated Management of Childhood Illness (CB-IMCI) in 2015 to create a unified approach (CB-IMNCI) to child survival [8, 9]

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