Looking for fire while carrying a lamp?

Evaluating the CB-NCP program implemented by

CARE Nepal from 2007 to 2011

SES

Village location

Ethnicity andCaste

Access to services

KAP of danger signs

Birth preparedness

Parity

Place of birth

Health facility equipment

Community commitment

Maternal nutrition

Infection

Continuum of care

Quality services

Skilled birth attendance

Cord care practices

Delivery complications

Preterm birth

Low birth weight

Asphyxia

Sepsis

Hypothermia

Neonatal Mortality

Determinants in the Causal Pathway of Neonatal Mortality

Key:

SDIP program

CB-NCP program

Evaluating the CB-NCP program

1. Is there evidence that home-based care is needed?

2. Is there evidence that the program achieved intermediate results?

3. Was there an impact on neonatal mortality?

Is there evidence that home-based care is needed?

2008-2011 Births Place of Death N (%)

Place of Birth Home Health facility Other Total

Home 172 (91.5) 4 (2.1) 12 (6.4) 188 (81.0)

Health facility 20 (62.5) 9 (28.1) 3 (9.4) 32 (13.8)

Other 5 (41.7) 1 8.3) 6 (50.0) 12 (5.2)

Total 197 (84.9) 14 (6.0) 21 (9.1) 232* (100)

• Overall, 85% of neonatal deaths occurred in the home• Use of health facilities increased from 16% in 2008 to 37% in

2011

Source: POSS and HMIS

Intermediate Results: Access and Quality of Services

0102030405060708090

100

Trends regarding quality and quantity of health care for mothers and newborns in Doti district from 2007 to 2011 (N=330)

20072011

Per

cen

tage

of

resp

ond

ents

Source: 2007, 2011 KPC survey

Intermediate Results: Improved Knowledge of Health Workers

keep baby dry don't apply anything on stump

breastfeed witin 1 hour

delay bath by 1 day0

20

40

60

80

100

120

43.8 43.8

55.350

100 10096

91.3

Pre and post-test scores for health facility workers before and after CRADLE newborn care practices training (N= 84)

Pre-test

Post-test

% t

hat

exp

ress

ed k

now

led

ge

Source: independent survey during midterm evaluation

Intermediate Results: Improved Knowledge of mothers

0

30

60

90

Trends among mothers in Doti district from 2007 to 2011 (N=330)

20072011

Percen

tag

e o

f resp

on

den

ts

*no baseline dataSource: 2007, 2011 KPC survey

Impact on Neonatal Mortality

April-

June

08

July

-Sep

08

Oct - D

ec 08

Jan-

Mar

09

April-

June

09

July

-Sep

09

Oct-Dec

09

Jan-

Mar

10

April-

June

10

July

-Sep

10

Oct-Dec

10

Jan-

Mar

110

10

20

30

40

50

60

70

58

25 2218

48

21

13 10

32

12

32

2125.8

18.515.4

Quarterly and annual trends in Neonatal Mortality in Doti District April 2008 to June 2011 (N=237)

Quarterly NMR

Year Total NMR

Dea

ths

per

1000

live

bir

ths

Reductions in Sepsis, Hypothermia, and Asphyxia

Sepsis Hypothermia LBW/preterm birth

Birth Asphyxia Other0

5

10

15

20

25

30

35

40

45

50

Causes of Neonatal Deaths from April 2008 to March 2011 (N=300)

April 2008-March 2009April 2009-March 2010April 2010-March 2011

Nu

mb

er o

f d

eath

s

Timing of neonatal deaths

April 2008 to March 2009 April 2009 to March 2010 April 2010 to March 20110

10

20

30

40

50

60

52

30

2023

14

10

17

71011

6

10

Day of Death among neonatal deaths from 2008 to 2011 in Doti (N=210)

with in 24 hour 24hr - 3 days 4-7 days 8-28 days

Nu

mb

er o

f d

eath

s

Influence of Place of Birth

April 2009 - March 2010 April 2010 - March 2011

Total NMR 18.46 15.4

home 15.7 13.39

health facility 20.11 15.57

2.5

7.5

12.5

17.5

22.5

Neonatal mortality rate by place of birth Doti district 2008 to 2011 (N=270)

Dea

ths

per

1000

live

bir

ths

*Source: POSS and HMIS

Knowledge on Asphyxia Treatment

wipe and massage baby use DeeLee suction use bag and mask0

20

40

60

80

100

120

70

95 96

89

100 98

Knowledge of Health workers and FCHVs regarding asphyxia treatment before and after training

FCHVs (N=112)Health workers (N=62)

% t

hat

exp

ress

ed c

omp

eten

cy

Evaluating the CB-NCP Program

1. Is there evidence that home-based care is needed? YES

2. Is there evidence that the program achieved intermediate results? YES

3. Was there an impact on neonatal mortality? YES

Conclusions

How CB-NCP compares with SDIP:

“SDIP did result in more women giving birth in the health facility, but did not result in a greater decrease in neonatal mortality”(3)

NDHS 2011 showed no real change in neonatal mortality since SDIP (implemented beginning 2005)

All of this suggests that CB-NCP works at least as well as SDIP at reducing neonatal mortality.There is a need for cost-benefit or cost-effectiveness analysis to ensure resources are used in the most effective way.

References

1)Lozano R, Wang H, Foreman KJ, Rajaratnam JK, Naghavi M, Marcus JR, Dwyer-Lindgren L, Lofgren KT, Phillips D, Atkinson C, Lopez AD, Murray CJ. (2011). Progress towards Millennium Development Goals 4 and 5 on maternal and child mortality: an updated systematic analysis. Lancet. 24;378(9797):1139-65.

2)UN Inter-agency Group on Child Mortality Estimation. (2011). Levels and Trends in Child Mortality, Report 2011. http://www.childinfo.org/files/Child_Mortality_Report_2011.pdf

3)Powell-Jackson T, Neupane BD, Tiwari S, Tumbahangphe K, Manandhar D, Costello AM. (2009). The impact of Nepal's national incentive programme to promote safe delivery in the district of Makwanpur. Advances in health economics and health services research. 21:221-249.