Child Health

CHILD HEALTH
MBBS 1ST YEAR
Dr Niki Shrestha. Assoc. Prof. Chitwan

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OBJECTIVES OF THE IOM SYLLABUS
• analyze the child health situation of the region
and Nepal
• describe the causes and childhood morbidity
and mortality - neonatal, infancy and under five
year old children.
• explain the mother's health and its relation
with child health
• describe the child survival strategies historical
perspective and the current approaches
Dr Niki Shrestha. Assoc. Prof. Chitwan Medi 2
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OBJECTIVES OF THE IOM SYLLABUS
• identify the social problems in children (child
abuse, abandoned or street children, child
labour, conflict and refugee situation and its
impact on child health)
• describe importance and methods of child
health surveillance
• analyze the importance of child rights and
protection in child development aspect

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• Prenatal Period:
Ovum = 0 to 14 Days
Embryo: 14 Days to 9 weeks
Foetus : 9th Week to Birth
• Premature Infant : from 28 to 37 weeks
• Birth, full term : average 280 days (37 wks to
41 wks)

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CHILDHOOD
• Infancy (upto 1 year of age)
 Neonatal Period (First 28 days of life)
 Post Neonatal Period ( 28th Day to 1 year)
• Pre-school age (1 to 4 Years)
• School Age ( 5 to 14 Years)

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CHILD HEALTH
WHO KEY FACTS
• Leading causes of death in children under-5
years are preterm birth complications, birth
asphyxia/trauma, pneumonia, congenital
anomalies, diarrhoea and malaria, all of which
can be prevented or treated with access to
simple, affordable interventions including
immunization, adequate nutrition, safe water
and food and quality care by a trained health
provider when needed.
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CHILD HEALTH
WHO KEY FACTS
• Injuries (including road traffic injuries and
drowning) are the leading causes of death
among older children.

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WHO IS MOST AT RISK?
CHILDREN UNDER 5
• Globally, infectious diseases, including
pneumonia, diarrhoea and malaria, along with
pre-term birth, birth asphyxia and trauma, and
congenital anomalies remain the leading
causes of death for children under five.

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CHILDREN UNDER 5
• Access to basic lifesaving interventions such as
skilled delivery at birth, postnatal care,
breastfeeding and adequate nutrition,
vaccinations, and treatment for common
childhood diseases can save many young lives.

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CHILDREN UNDER 5
• Malnourished children, particularly those with
severe acute malnutrition, have a higher risk
of death from common childhood illness such
as diarrhoea, pneumonia, and malaria.
• Nutrition-related factors contribute to about
45% of deaths in children under-5 years of
age.

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Global response:
Sustainable Development Goal 3.2.1
• The Sustainable Development Goals (SDGs) adopted by

the United Nations in 2015 were developed to
promote healthy lives and well-being for all children.
• The SDG Goal 3.2.1 is to end preventable deaths of
newborns and under-5 children by 2030.
• There are two targets:
1. Reduce newborn mortality to at least as low as 12
per 1 000 live births in every country; and
2. Reduce under-five mortality to at least as low as 25
per 1,000 live births in every country.
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Global response:
• Target 3.2.1 is closely linked with target 3.1.1,

to reduce the global maternal mortality ratio
to less than 70 deaths per 100 000 live births,
and target 2.2.1 on ending all forms of
malnutrition, as malnutrition is a frequent
cause of death for under-5 children.

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Global response:
• Meeting the SDG target would reduce the

number of under-5 deaths by 11 million
between 2019 and 2030.
• Focused efforts are still needed in Sub-
Saharan Africa and South East Asia to prevent
80 per cent of these deaths.

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Children: New Threats to Health
• Greenhouse gas emissions leading to climate
change and ecological degradation
existentially threaten the lives of all children.
• Children are vulnerable to adverse health
effects from indoor and outdoor air pollution
which causes an estimated 7 million deaths
per year (2016).
WHO
Dr Niki Shrestha. Assoc. Prof. Chitwan Medi
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Children: New Threats to Health
• There are 124 million children and adolescents
affected by obesity (2016).
• Children are frequently exposed to
commercial marketing promoting addictive
substances and unhealthy commodities.
• Road injury is the leading cause of death for
children and young people; more than 1
billion children are exposed to violence every
year. WHO
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MATERNAL AND CHILD HEALTH
DEFINITION
• The term "maternal and child health" refers to
the promotive, preventive, curative and
rehabilitative health care for mothers and
children.
• It includes the sub- areas of maternal health,

child health , family planning, school health,
handicapped children and health aspects of care
of children in special settings such as day care.
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OBJECTIVES OF MCH
(a) reduction of maternal, perinatal, infant and
childhood mortality and morbidity:
(b) promotion of reproductive health ; and
(c) promotion of the physical and psychological

development of the child and adolescent
within the family.
The ultimate objective of MCH services is life-

long health. Dr Niki Shrestha. Assoc. Prof. Chitwan
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MOTHER AND CHILD - ONE UNIT
• During the antenatal period, the foetus is part of
the mother.
• The period of development of foetus in mother

is about 280 days .
• During this period, the foetus obtains all the

building materials and oxygen from the
mother's blood;
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• Child health is closely related to maternal
health. A healthy mother brings forth a
healthy baby; there is less chance for a
premature birth, stillbirth or abortion
• Certain diseases and conditions of the mother

during pregnancy (e.g syphilis, german
measles, drug intake) are likely to have their
effect upon the foetus

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• After birth, the child is dependent upon the
mother.
• At least up to the age of 6 to 9 months, the

child is completely dependent on the mother
for feeding .
• The mental and social development of the

child is also dependent upon the mother.
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• If the mother dies, the child's growth and
development are affected (maternal
deprivation syndrome)
• The mother is also the first teacher of the

child.
• It is for these reasons, the mother and child

are treated as one unit.

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• In the past, maternal and child health services
were rather fragmented, and provided
piecemeal "personal health services" by
different agencies, in different ways and in
separate clinics.
• The current trend in many countries is to

provide integrated MCH and family planning
services as compact family welfare service .

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• This implies a close relationship of maternity
health to child health, of maternal and child
health to the health of the family ; and of
family health to the general health of the
community.

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• In providing these services, specialists in
obstetrics and child health (paediatrics) have
joined hands, and are now looking beyond the
four walls of hospitals into the community to
meet the health needs of mothers and
children aimed at positive health.

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• In the process, they have linked themselves to
preventive and social medicine, and as a
result, terms such as "social obstetrics",
"preventive paediatrics" and "social
paediatrics have come into vogue .

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INTRANATAL PERIOD
DEFINITION
• During or at the time of birth
• Consists of taking care of not only the mother

but also the new born at the time of child-
birth

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INTRANATAL CARE
“6 Cs” advocated by WHO
• The emphasis is on the cleanlines !!
1. Clean hands - hand washing of birth
attendant before birth,
2. Clean birth surface,
3. Clean perineum (Clean birth canal)
4. Cutting of the umbilical cord using a clean
implement,
5. Clean cord tie, and
6. Clean cloth for drying

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INTRANATAL CARE
6 Cs helps to prevent infection like:
Neonatal tetanus
Ophthalmia Neonatorum or neonatal
conjunctivitis
Puerperal sepsis
and thus reduce IMR and MMR

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AIMS OF GOOD INTRA-NATAL CARE
 Thorough asepsis
 Delivery with minimum injury to the infant
and mother
 Readiness to deal with complications such as
prolonged labour, antepartum haemorrhage,
convulsions, malpresentations, prolapse of the
cord, etc.
 Care of the baby at delivery, resuscitation,
care of the cord, care of the eyes, etc.
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AIMS OF GOOD INTRA-NATAL CARE
 To promote clean and safe delivery.
 To prevent infections in both the mother and
new born.
 To recognize the ‘danger signals’ and be ready
to manage them.
 To take immediate and essential care of new
born at birth.
 To reduce IMR and MMR.

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COMPONENTS OF DELIVERY CARE SERVICES IN NEPAL
Delivery care services in Nepal, include:

• SBA/skilled health personnel provider (SHP) at
• facility-based deliveries
• early detection of complicated cases and
management or referral (after providing obstetric
first aid) to an appropriate health facility where 24
hours emergency obstetric services are available;
• Registration of maternal death and neonatal birth
and death
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DELIVERY AT HEALTH FACILITIES IN NEPAL
• The percentage of pregnant women delivering
at the health facilities has shown a steady
increase over the past three FYs with 83.4%
institutional deliveries in FY 2079/80.
Madhesh and Gandaki provinces have lower
coverage as compared to national average
over the period of the three years

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Percentage of pregnant women delivering at the health facilities in FYs
2077/78-79/80

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DELIVERIES ATTENDED BY SHP /SBA IN NEPAL
• In FY 2079/80, 79.8% of the deliveries were attended

by SBA/SHP.
• Three provinces- Bagmati (98.5%), Lumbini (92.7%),

and Koshi (82.7%), have higher percentage of deliveries
attended by SBA or SHP than national average.
• Notably there is consistent improvement in Karnali,

Madhesh and Gandaki provinces but these changes are
lower than the national averages.
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DELIVERIES ATTENDED BY SHP /SBA IN
NEPAL
• Though from FY 2079/80, there are two set of
indicators sub-categorized as SBA (registered
ANMs who have got SBA training) and SHP
(nurses and doctors), they have been
combined for ease of comparison.
• In previous years, both were jointly reported
as one indicator.
• In years ahead, the disaggregated data on SBA
and SHP deliveries can be compared.
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MAIN FACTORS THAT AFFECT
DELIVERY CARE IN NEPAL
• Lack of transportation,
• Long distance to the health facility,
• Unfriendly provider’s attitude
• Poor service delivery systems and physical
infrastructure,

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• High parities, low education status,
• Low perceived attitude towards safer
pregnancy and delivery care,
• Rural residence,
• Gender inequality,

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• Traditional socio-cultural practices and faiths
towards delivery care,
• Low decision making power and
socioeconomic status of women,
• Geographic constraints

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POSTNATAL CARE
DEFINITION
• Care of the mother (and the newborn) after
delivery is known as postnatal or post-partal
care (Up to 6 Weeks)

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POSTNATAL CARE
• Broadly this care falls into two areas: care of
the mother which is primarily the
responsibility of the obstetrician; and care of
the newborn, which is the combined
responsibility of the obstetrician and
paediatrician.
• This combined area of responsibility is also

known as peri-natology.

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OBJECTIVES OF POST-NATAL CARE
(1) To prevent complications of the postpartal
period.
(2) To provide care for the rapid restoration of
the mother to optimum health.
(3) To check adequacy of breast feeding
(4) To provide family planning services
(5) To provide basic health education to
mother/family
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POST-NATAL CARE
• The 48 hours immediately following
birth is the most crucial period for
newborn survival.
• This is when the mother and child

should receive follow-up care to prevent
and treat illness.

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POST-NATAL CARE
• Prior to birth, the mother can increase her
child's chance of survival and good health by
attending antenatal care consultations, being
immunized against tetanus, and avoiding
smoking and use of alcohol.
• At the time of birth, a baby's chance of

survival increases significantly with delivery in
a health facility in the presence of a skilled
birth attendant.
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POST-NATAL CARE
(ESSENTIAL NEWBORN CARE)
All babies should receive the following:

• thermal protection (e.g. promoting skin-to-skin contact
between mother and infant);
• hygienic umbilical cord and skin care;
• early and exclusive breastfeeding;
• assessment for signs of serious health problems or need
of additional care (e.g. those that are low-birth-weight,
sick or have an HIV-infected mother
• preventive treatment (e.g. immunization BCG and
Hepatitis B, vitamin k and ocular prophylaxis)
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POST-NATAL CARE
(ESSENTIAL NEWBORN CARE)
Families should be advised to:
• seek prompt medical care if necessary (danger signs
include feeding problems, or if the newborn has reduced
activity, difficult breathing, a fever, fits or convulsions, or
feels cold);
• register the birth;
• bring the baby for timely vaccination according to national
schedules.
• Some newborns require additional attention and care
during hospitalization and at home to minimize their
health risks.
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POSTNATAL CARE
(For Mothers)
Proper service and care should be provided to
mother for physical, mental and social
restoration.

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POSTNATAL CARE
(For Mothers)
1. Physical restoration
 General and physical examination.
 Assess anemia and maintain Hb level.
 Provision of proper nutrition.
 Advice mother for postnatal exercise.

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POSTNATAL CARE
(For Mothers)
2. Psychological restoration
 Proper raring and caring of mother and
children.
 Proper family support.
 Remove anxiety and stress.
 Assurance to mother.

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POSTNATAL CARE
(For Mothers)
3. Social restoration
Support by family members specially by
husband.
Support by social members.

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POSTNATAL CARE
(For Mothers)
Proper breastfeeding:
Encourage colostrum feeding and help mother
for exclusive breastfeeding up to 6 months.
Family Planning Services:
FP counseling, spacing for next birth.
If family size is completed, advice for
permanent sterilization.

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POSTNATAL CARE
(For Mothers)
Basic Health Education to mother:
Personal hygiene and sanitation.
Care of children.
Importance of health check up.
Birth registration.
Periodical immunization.
Growth monitoring. etc

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MAJOR MATERNAL COMPLICATIONS
OF POSTNATAL PERIOD
• Puerperal sepsis: Infection of the genital tract
within 3 weeks after delivery, Puerperal sepsis
can be prevented by attention to asepsis,
before and after delivery.
• Thrombophlebitis: Infection of the veins of

the legs, frequently associated with varicose
veins.

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MAJOR MATERNAL COMPLICATIONS
OF POSTNATAL PERIOD
• Post partum haemorrhage: Bleeding from
vagina anytime from 6 hours after delivery to
the end of the puerperium (6 weeks) is called
post partum haemorrhage, and may be due to
retained placenta or membranes.

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OBJECTIVES OF POSTNATAL CARE
(FOR CHILDREN)
 To provide immediate and essential care to

the new born.
 To prevent neonatal complication such as
infections, hypothermia and birth asphyxia.
 To educate mother about ‘danger signs’ of
new born.

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OBJECTIVES OF POSTNATAL CARE
(FOR CHILDREN)
 To detect ‘at- risk’ new born and give the

special attention.
 To promote growth and development.
 To educate the parents for love and security.
 To reduce perinatal and early neonatal
mortality rate.

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POSTNATAL CARE
DANGER SIGNS OF NEW BORN
•Every mother should be educated about danger
sign of new born so that she can recognize and
take new born to medical care immediately.

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POSTNATAL CARE
DANGER SIGNS OF NEW BORN
 Refusal to feed.
 Increased drowsiness.
 Cold to touch.
 Difficult or rapid breathing.
 Convulsions.
 Persistent vomiting.
 Jaundice at birth.
 Blue colour of extremities.

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POSTNATAL CARE
IMMEDIATE CARE OF THE NEWBORN
• Clearing the airway
• APGAR Score
• Care of the umbilical cord
• Care of the eyes
• Care of the skin
• Maintenance of body temperature (Rooming-
in)
• Breast Feeding
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POSTNATAL CARE
CARE OF THE UMBILICAL CORD
• In the case of the normal infant, the umbilical
cord should be cut and tied when it has
stopped pulsating.
• The advantage is that the baby derives about
10 ml of extra blood, if the cord is cut after
pulsation ceases.
• This is particularly important in Nepal where
anaemia is frequent

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POSTNATAL CARE
CARE OF THE UMBILICAL CORD
• Care must be taken to prevent tetanus of the
newborn by using properly sterilized instruments
(Clean cut) and cord ties (clean tie).
• It is essential to apply an antiseptic chlorhexidine

on the cord stump.
• The cord dries and shrivels up and separates by

aseptic necrosis in 5-8 days.
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CHLORHEXIDINE NAVI (CORD) CARE PROGRAM OF NEPAL
• The Chlorhexidine Navi Care (CNC) Program is

working to reduce newborn deaths in Nepal
through the use of chlorhexidine to prevent
neonatal sepsis.
• In a pilot study, use of the antiseptic

chlorhexidine for umbilical cord ("navi") care
was proven to reduce the risk of death by 24
percent in Nepal.

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CHLORHEXIDINE NAVI (CORD)
CARE PROGRAM OF NEPAL
• Working with a local pharmaceutical firm and
the Ministry of Health and Population, JSI
(John Snow Inc.) is rapidly and sustainably
increasing demand, availability, and use of the
product on a national scale.

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• Cleansing newborn umbilical cord stumps with

7.1% Chlorhexidine Digluconate solution has
been demonstrated to reduce newborn
mortality by 23 percent.
• Chlorhexidine in a gel formulation has been

found more acceptable to users; this product
was developed and piloted in Nepal.

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• After the success of the pilot, the Nepal

Government endorsed use of chlorhexidine
for cord care as a part of essential newborn
care in December 2011.
• By the start of 2013, Nepal has moved

forward as the first country in the world to
adopt chlorhexidine for newborn cord care.

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CHLORHEXIDINE NAVI (CORD) CARE
PROGRAM OF NEPAL
• Chlorhexidine gel should be applied
immediately after birth (within one hour)

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PROGRAM OF NEPAL
• Even though government of Nepal has the
policy of mandatory institutional deliveries
because of various reasons women cannot
reach up to health centres for delivery.
• So in case of any home deliveries in their
locality FCHVs provide support and care to the
postpartum women and new born.

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PROGRAM OF NEPAL
• Chlorhexidine application for newborn
umbilical cords (HF+FCHV) was reported at
83% nationally in FY 2079/80.
• However, there was notably low coverage in
Bagmati Province (57%)

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COMPONENTS OF POSTNATAL
CARE SERVICES/VISITS IN NEPAL
• Guideline encouraged all women for
institutional delivery and stay in the health
facility at least for 24 hours after delivery
under the supervision and care of health
workers as first 24 hours of delivery.
• The brief postnatal care/ visit covers the
following:

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COMPONENTS OF POSTNATAL
CARE SERVICES/VISITS IN NEPAL
1. Four postnatal check-ups, the first in 24 hours
of delivery at the health facility, the second on
the third day at home, third on the seventh to
fourteenth at home and fourth on the 42 days
after delivery at health facility.
2. Identification and management of
complications of mothers and newborns, care
immediately at health facility and referrals to
appropriate health facilities from community.
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COMPONENTS OF POSTNATAL CARE
SERVICES/VISITS IN NEPAL
3. Breastfeeding as soon within one hour of
delivery and promotion of exclusive
breastfeeding.
4. Personal hygiene and nutrition education, and
postnatal vitamin A and iron supplementation for
mothers.
5. Immunization of newborns.
6. Postpartum family planning (PPFP) counselling
and services.
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POST NATAL SERVICE COVERAGE IN NEPAL
• The proportion of mothers attending three

Postnatal Check Up (PNC) visits as per the
protocol increased remarkably by nearly
16.0% points from FY 2077/78 to 2078/79.
• In FY 2079/80, this increased by nearly 3.0%
points with 44.0% PNC coverage of three PNC
visits. Lumbini (68.0%), Sudurpaschim (61.0%)
and Karnali (57.0%) provinces surpassed the
national average.
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POST NATAL SERVICE COVERAGE IN NEPAL
• Among remaining four provinces, the coverage of

three PNC visits has consistently been lower in
Madhesh Province.
• Socio-cultural factors, improving perception on
importance of care during postpartum period may
be the possible areas to intervene.
• Furthermore, learnings from the provinces
performing well can be reviewed to bring up
implementation strategy that may improve
coverage in other provinces as well.
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PNC VISITS IN NEPAL

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Gap in Coverage of Care Utilization
from Pregnancy to Postnatal Phase in Nepal
• There is a notable gap between the uptake of
4-ANCs (93.5%) and 3-PNCs as per protocol
(44.2%) in FY 2079/80 which is a consistent
gap seen across three FYs.
• Remarkable gaps are also observed at
interprovincial level.

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Gap in Coverage of Care Utilization
from Pregnancy to Postnatal Phase in Nepal
• The emphasis on counselling during each point
of contact and integration of the PNC services
with immunization and family planning are some
initiatives of FWD that can be further
investigated to see the role in fulfilling the gaps.
• Additionally, with high CS rates, the standardized
PNC care becomes more essential to reduce
postnatal morbidities in women post CS.

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COMPONENTS OF NEWBORN
CARE SERVICES IN NEPAL
• delivery by a skilled birth attendant at home and
facility births with immediate newborn care (warmth,
cleanliness, immediate breast feeding, cord care, eye
care and immunization) for all newborns and the
resuscitation of newborns with asphyxia;
• health education and behavior change
communication on early newborn care at home;
• identification of neonatal danger signs and timely
referral to the appropriate health facility;
• Community based newborn care
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Causes of newborn admission across
provinces reported in FY 2079/80

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AT RISK INFANTS
1. Birth weight less than 2.5 kg
2. Twins
3. Birth order 5 and more
4. Artificial feeding

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AT RISK INFANTS
5. Weight below 70 per cent of the expected
weight (i .e. II and III degrees of malnutrition)
6. Failure to gain weight during three successive
months
7. Children with PEM, diarrhoea
8. Working mother/one parent

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AT RISK INFANTS
9. Birth asphyxia.
10. Birth injury.
11. Loss of mother.
12. Illegitimate child.
13. Jaundice at birth.

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AT RISK INFANTS
14. APGAR Score < 5.
15. Mother un-immunized with Td injection.
16. Born of mother infected with Hepatitis B,
HIV/AIDS, Syphilis, TB, etc.

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PRE-TERM, TERM AND POST-TERM BABIES
Pre - term : Babies born before the end of 37

weeks gestation (less than 259 days) .
Term : Babies born from 37 completed weeks to

less than 42 completed weeks (259 to 293 days)
of gestation.
Post- term : Babies born at 42 completed weeks

or any time thereafter (294 days and over) of
gestation .
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LOW BIRTH WEIGHT
• The birth weight of an infant is the single most

important determinant of its chances of
survival, healthy growth and development.
• There are two main groups of low birth

weight babies - those born prematurely
(short gestation) and those with foetal
growth retardation.

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LOW BIRTH WEIGHT
• In countries where the population of low birth
weight infants is less, short gestation period is
the major cause.
• In countries where the proportion is high, the

majority of cases can be attributed to foetal
growth retardation.

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LOW BIRTH WEIGHT
• By international agreement low birth weight
has been defined as a birth weight of less than
2.5 kg {up to and including 2499 g) , regardless
of gestational age, the measurement being
taken preferably within the first hour of life,
before significant postnatal weight loss has
occurred.
• It includes two kinds of infants :

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LOW BIRTH WEIGHT
PRE- TERM BABIES
• These are babies born too early, before 37 weeks
of gestation.
• Their intrauterine growth may be normal. That is,

their weight, length and development may be
within normal limits for the duration of gestation.
• Given good neonatal care , these babies can

catch up growth and by 2 to 3 years of age will be
of normal size and performance.
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LOW BIRTH WEIGHT
PRE- TERM BABIES
• Approximately two- thirds of all babies of LBW
in developed countries are estimated to be
pre-term.
• The causation of preterm babies is

multifactorial. These include multiple births,
acute infections, hard physical work,
hypertensive disorders of pregnancy, etc.

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LOW BIRTH WEIGHT
PRE- TERM BABIES
• In many cases the cause is not known. But it is
often preventable by such measures as good
prenatal screening and care, the
discouragement of adolescent pregnancy and
treatment of hypertension .

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LOW BIRTH WEIGHT
SMALL- FOR-DATE (SFD) BABIES
• These may be born at term or pre-term . They
weigh less than the 10th percentile for the
gestational age.
• These babies are clearly the result of retarded

intrauterine foetal growth .

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LOW BIRTH WEIGHT
• The factors associated with intrauterine
growth retardation are multiple and
interrelated to mother, the placenta or to the
foetus.

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LOW BIRTH WEIGHT
• The maternal causes include malnutrition,
severe anaemia , heavy physical work during
pregnancy, hypertension, malaria, toxaemia,
smoking, low economic status, short
maternal stature, very young age , high parity
and close birth spacing, low education status
etc .

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LOW BIRTH WEIGHT
• The placental causes include placental
insufficiency and placental abnormalities.
• The foetal causes include foetal abnormalities,

intrauterine infections, chromosomal
abnormality and multiple gestation.

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LOW BIRTH WEIGHT
• SFD babies have a high risk of dying not only
during the neonatal period but during their
infancy, thus significantly raising the rate of
infant and perinatal mortality and contribute
greatly to immediate and long term health
problems.
• Most of them become victims of protein-

energy malnutrition and infections.

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CAUSES OF LOW BIRTH WEIGHT
A. Maternal cause:
High risk mother except a diabetic mother.
B. Placental Cause:
Placental insufficiency.
Placenta previa.
Premature separation of placenta.
Congenital defect of placenta.

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C. Fetal Causes:
Twins, triplets, quadruplets.
Fetal abnormalities and defects.
Intra-uterine infection.
Chromosomal abnormalities.

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D. Social Causes:
Poverty.
Illiteracy.
Ignorance
Poor standard of living.
Lack of knowledge on FP.
Early marriage.
Smoking.
 Heavy work during pregnancy.
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Problems Faced By LBW Babies
Infection.
Hypothermia.
Respiratory distress syndrome.
Meconium aspiration syndrome.
Malnutrition.
Apnea.
Anemia.

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Problems Faced By LBW Babies
Hypoxia.
Multiple-system complication.
Poor survival.
High mortality.

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LEADING CAUSES OF DEATH IN
LOW BIRTH WEIGHT BABIES
a. Atelectasis (collapse of the lung)

b . malformation
c. pulmonary haemorrhage
d. intracranial bleeding, secondary to anoxia or
birth trauma
e. pneumonia and other infections.

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PREVENTION OF LOW BIRTH
WEIGHT
1. Direct intervention measures:
Prevention of malnutrition.
Prevention of anemia.
Control of medical infections.
Avoidance of strenuous exercise during
pregnancy.

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PREVENTION OF LOW BIRTH WEIGHT
2. Indirect intervention measures:

Avoidance of marriage at very young age
Proper planning of pregnancy
Proper spacing between children
Improvement in literacy level, living
condition, quality of life, etc.
Improvement of availability of health services
to women

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INDICATORS OF MCH CARE
1. Maternal mortality rate
2. Mortality in infancy and childhood:

a. Perinatal mortality rate
b. Neonatal mortality rate
c. Post-neonatal mortality rate

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INDICATORS OF MCH CARE
2. Mortality in infancy and childhood:
d. Infant mortality rate
e. 1-4 year mortality rate
f. Under 5 mortality rate
g. Child survival rate

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MORTALITY - TERMINOLOGY

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Definitions of Early Childhood Mortality
• Neonatal mortality: The probability of dying within the first
month of life.
• Postneonatal mortality: The probability of dying between
the first month of life and the first birthday (computed as
the difference between infant and neonatal mortality).
• Infant mortality: The probability of dying between birth
and the first birthday.
• Child mortality: The probability of dying between the first
and fifth birthday.
• Under-5 mortality: The probability of dying between birth
and the fifth birthday.
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Nepal’s Targets in U5MR and NMR
• The government of Nepal’s target for SDG
3.2.1, is to reduce the under-five mortality
rate to 27 deaths per 1,000 live births by 2022
and to 20 deaths per 1,000 live births by 2030.
• The government’s target for SDG 3.2.2, is to
reduce the neonatal mortality rate to 16
deaths per 1,000 live births by 2022 and to 12
deaths per 1,000 live births by 2030 (National
Planning Commission, 2020).
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CHILD MORTALTIY IN NEPAL
[ REF. NDHS 2022]
• During the 5 years immediately preceding the
survey, the overall under-5 mortality rate was
33 deaths per 1,000 live births.
• The infant mortality rate was 28 deaths per
1,000 live births.
• The child mortality rate was 5 deaths per
1,000 children surviving to age 12 months.

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CHILD MORTALTIY IN NEPAL
[ REF. NDHS 2022]
• The neonatal mortality rate was 21 deaths per
1,000 live births, during the 5 years
immediately preceding the survey.
• Eighty-five percent (85%) of all deaths among
children under age 5 in Nepal take place
before a child’s first birthday, with 64%
occurring during the first month of life.

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Trends in early childhood mortality rates in
Nepal
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Trends in early childhood mortality rates in
Nepal
• Trends: Between the 1996 NFHS and the 2022
NDHS surveys, under-5 mortality declined from
118 to 33 deaths per 1,000 live births, infant
mortality declined from 78 to 28 deaths per
1,000 live births, and neonatal mortality declined
from 50 to 21 deaths per 1,000 live births.
• Notably, however, between the 2016 and 2022
NDHS the neonatal mortality did not change.

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WHAT WERE THE BIGGEST THREATS TO
CHILDREN UNDER FIVE IN DEVELOPING
COUNTRIES?
1. Neonatal Causes
2. Pneumonia
3. Diarrhoea
4. Malaria
5. Measles
6. HIV/AIDS
7. Malnutrition

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SHARE OF GLOBAL UNDER -5 DEATHS BY WHO
REGION [1990-2018]
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GLOBAL UNDER-FIVE MORTALITY
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CAUSES OF CHILD MORTALITY
• The majority of all neonatal deaths (75%) occurs during the
first week of life, and about 1 million newborns die within
the first 24 hours.
• Preterm birth, intrapartum-related complications (birth
asphyxia or lack of breathing at birth), infections and birth
defects cause most neonatal deaths in 2017.
• From the end of the neonatal period and through the first 5
years of life, the main causes of death are pneumonia,
diarrhoea, birth defects and malaria. Malnutrition is the
underlying contributing factor, making children more
vulnerable to severe diseases.
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Global Major Causes of U5 child Mortality
in 2015 (WHO)

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Distribution of causes of death in Nepal among
children aged <5 years (%)(WHO, 2015)
0-27 DAYS 1-59 MONTHS
HIV/AIDS 0 0.8
DIARRHOEAL DISEASES 0.7 14.2
PERTUSIS 0.2 6.4
TETANUS 0.7 0
MEASLES 0 2.6
MENINGITIS/ENCEPHALITIS 0 4.2
MALARIA 0 0
ALRTI 5.6 29.5
PREMATURITY 30.8 2.8
BIRTH ASPHYXIA AND BIRTH TRAUMA 23.4 2.3
SEPSIS AND OTHER INFECTIOUS CONDITIONS OF THE NEWBORN 18.4 0
OTHER COMMUNICABLE, PERINATAL AND NUTRITIONAL CONDITIONS 6 7.8
CONGENITAL ANOMALIES 13.4 4
OTHER NCDs 0.1 10.3

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INJURIES 0.8 14.9
INFANT MORTALITY RATE (IMR)
• Infant mortality rate (IMR) is defined as "the

ratio of infant deaths registered in a given year
to the total number of live births registered in
the same year; usually expressed as a rate per
1000 live births"

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The “Two Third Rule”
on Global IMR
• Almost two-thirds of infant deaths occur in the
first month of life.
• Among those who die in the first month of life,

about two thirds die in the first week of life.
• Among those who die within the first week,

two thirds die in the first 24 hours of life.

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IMR Calculation
Number of deaths of children less than 1 year
of age in a year
________________________________ x 1000
Number of live births in the same year

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MEDICAL CAUSES OF INFANT MORTALITY
NEONATAL MORTALITY (0-4 WEEKS)
• LBW and pre-maturity

• Birth injury and difficult labour
• Sepsis
• Congenital anomalies
• Haemolytic diseases of new born
• Conditions of placenta and cord
• Diarrhoeal diseases
• ARI
• Tetanus
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MEDICAL CAUSES OF INFANT MORTALITY
POST-NEONATAL MORTALITY
( 1-12 MONTHS)
• Diarrhoeal Diseases
• ARI
• Other communicable diseases
• Malnutrition
• Congenital Anomalies
• Accidents

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FACTORS AFFECTING INFANT MORTALITY
BIOLOGICAL FACTORS
• Birth weight
• Age of the mother
• Birth order
• Birth Spacing
• Multiple Births
• Family Size
• High Fertility

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ECONOMIC FACTORS
• The availability and quality of health care and the
nature of the child's environment are closely related
to socioeconomic status.
• Statistics reveal that infant mortality rates are highest

in the slums and lowest in the richer residential
localities.
• Major improvements in health status and a decrease

in infant mortality require continuing socioeconomic
development, including provision of health services.
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CULTURAL AND SOCIAL FACTORS
• Breast-feeding
• Religion and caste
• Early marriages
• Sex of the child

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CULTURAL AND SOCIAL FACTORS
• Quality of mothering
• Maternal education
• Quality of health care
• Broken families
• Illegitimacy
• Bad environmental sanitation

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BRUTAL HABITS AND CUSTOMS
• Depriving the baby of the first milk or

colostrum, application of cowdung to the cut
end of umbilical cord, faulty feeding practices
and early weaning.

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UNTRAINED HEALTH WORKER
• She is usually an illiterate person devoid of all
knowledge of rules of hygiene. Her unhygienic
delivery practice is an important cause of high
infant mortality.

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BAD ENVIRONMENTAL SANITATION
• Infants are highly susceptible to bad

environmental sanitation.
• Lack of safe water supply, poor housing

conditions, bad drainage, over-crowding, and
insect breeding, all increase the risk of infant
mortality.

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MEASURES NEEDED TO ACHIEVE
REDUCTION OF INFANT MORTALITY
• Prenatal nutrition
• Prevention of infection
• Breast-feeding
• Growth monitoring

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MEASURES NEEDED TO ACHIEVE
REDUCTION OF INFANT MORTALITY
• Family planning
• Sanitation
• Provision of primary health care
• Socio-economic development
• Education

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UNDER - 5 MORTALITY RATE
• UNICEF defines this as the "annual number of deaths

of children age under 5 years, expressed as a rate per
1000 live births. "
• More specifically, it measures the probability of

dying between birth and exactly 5 years of age.
• UNICEF considers this as the best single indicator of

social developments and well-being as it reflects
income, nutrition , health care and basic education,
etc
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U5 MR Calculation
No of deaths of children less than 5 yrs of age
in a given year
________________________________ x 1000
Number of live births in the same year

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Neonatal Mortality Rate
• Probability of dying within the first month of
life.

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Neonatal Mortality in Nepal
• According to global statistics and hospital
based data in Nepal, major causes of
newborn deaths in Nepal are infection, birth
asphyxia, preterm birth, and hypothermia.
• Three-quarters of all newborn deaths occur
during the first week of life, 25–45% in the
first 24 hours. This is also the period when
most maternal deaths occur.

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• Hospital based data suggest that the major
direct causes of neonatal death in Nepal are:
 Infection
 Birth asphyxia/trauma
 Prematurity
 Hypothermia

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• Underlying these direct causes is a constellation
of underlying causes, including: poor pre-
pregnancy health,
 inadequate care during pregnancy,
 inadequate care during delivery,
 low birth weight, and
 inadequate newborn and postpartum care.
• Fundamental to these underlying causes is the

low status and priority given to women and
newborns.
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Causes of newborn deaths FY 2079/80 in
Nepal

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Every Newborn Action Plan (ENAP)
• Every Newborn Action Plan (ENAP) was
endorsed at the 67th World Health Assembly in
2014.
• The global Every Newborn Action Plan (ENAP),
launched in 2014, includes clear targets and
strategies for reducing neonatal deaths and
stillbirths and supports the United Nations
Secretary-General’s Every Woman Every Child
initiative (EWEC).
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Nepal’s Every Newborn Action Plan
(NENAP)
•
With the vision of a country where ‘there is no preventable
deaths of newborns or stillbirths, where every pregnancy is
wanted, every birth celebrated and women, babies and
children survive, thrive and reach their full potential MoHP
has initiated NENAP through four strategic directions which
are equitable utilization of health services, quality for all,
multi-sectoral approach and reform, particularly for poor
and vulnerable populations.
• NENAP aims to achieve NMR of less than 11 deaths per
1000 live births and a stillbirth rate of less than 13
stillbirths per 1000 total births by the year 2035.
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(NENAP)
• There is a particular focus on NMR because
the babies dying in the first 28 days after birth
contribute significantly to the under-five
mortality despite the drastic reduction.

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(NENAP)
• The NENAP is an integrated and collaborative
effort developed under the joint leadership of
the country’s Family Health and Child Health
divisions of the Ministry of Health, and guided
by the universal health coverage approach
adopted by the National Health Policy of 2014.

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(NENAP)
• The Plan adopts four strategic directions:
equitable utilization of health services, quality
for all, a multi-sectoral approach, and reform.
It is integrated within the broader National
Health Sector Strategy (NHSS, 2015–2020).

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Prevention of Neonatal Hypothermia
The concept of "Warm Chain"
• Baby must be kept warm at the place of birth
(home or hospital) and during transportation
for special care either from home to hospital
or within the hospital.
• Satisfactory control demands both prevention

of heat loss and promotion of heat gain.

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• The "warm chain" is a set of ten interlinked
procedures carried out at birth and later,
which will minimize the likelihood of
hypothermia in all newborns.

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1. Warm delivery room (> 25°C)
2. Warm resuscitation
3. Immediate drying
4. Skin-to-skin contact between baby and the
mother
5. Breastfeeding

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6. Bathing and weighing postponed
7. Appropriate clothing and bedding
8. Mother and baby together
9. Warm transportation
10. Training/awareness of healthcare providers

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Kangaroo Mother Care (KMC)
• Kangaroo Mother Care is a method of care
practiced on babies, usually on a preterm
infant, where the infant is held skin-to-skin
with his mother, father, or substitute
caregiver.

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(Maya Ko Angalo)

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Kangaroo Mother Care (KMC) serves as a
natural and best incubator, like the animal
kangaroo, keeping the young in its pouch.
KMC is scientifically proved to be highly

superior to existing sophisticated technologies
available.

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Kangaroo position
• Place the baby between the mother’s breasts
in an upright position, chest to chest.

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Kangaroo position
• Secure him with the binder. The head, turned
to one side, is in a slightly extended position.
• The top of the binder is just under baby’s ear.

This slightly extended head position keeps the
airway open and allows eye-to-eye contact
between the mother and the baby

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Kangaroo position
• Avoid both forward flexion and
hyperextension of the head.
• The hips should be flexed and extended in a

“frog” position; the arms should also be
flexed.

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Kangaroo position
• Tie the cloth firmly enough so that when the
mother stands up the baby does not slide out.
Make sure that the tight part of the cloth is
over the baby’s chest.

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Kangaroo position
• Baby’s abdomen should not be constricted
and should be somewhere at the level of the
mother’s epigastrium.
• This way baby has enough room for abdominal

breathing. Mother’s breathing stimulates the
baby

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• A baby who is born LBW (less than 2500 g)
often needs special care in a hospital.
• If there are no signs of distress or extreme

prematurity, a mother can provide warm
environment by "Kangarooing" the baby at
home or hospital.

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KMC should be started soon after birth, in low
and very low weight babies and continued 24
hrs a day till the baby gains 2000g.

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• If environmental temperature is low, dress the
baby with extra clothing and cover his head.
• When mother wants to bathe or rest, ask the

father or another family member to
'Kangaroo’ the baby or wrap infant in several
layers of warm clothing, covered with blankets
and keep in a warm place.

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Advantages of Kangaroo Mother
Care (KMC)
 Assists in maintaining the temperature of
infant
 Facilitates breastfeeding
 Helps to increase the duration of
breastfeeding
 Improves mother infant bonding

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Advantages of Kangaroo Mother Care
(KMC)
 Provides Warmth ( prevents hypothermia)
 Promotes growth (by exclusive BF)
 Protects from cross infection (cross-infection of
hospital)
 Provides caring environment
 Is a low cost method and doesn’t required
incubator.
 It is initiated in hospital and can be continued at
home.
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KANGAROO MOTHER CARE PROGRAM IN
NEPAL
• Kangaroo mother care (KMC) is a proven, cost-effective
intervention to care for stable preterm/LBW babies that is
being implemented by Government of Nepal as a special care
for small and/or sick new-born.
• Skin to skin contact has been part of different programs/
training packages such as CB-IMNCI, FB-IMNCI, SBA Training,
Comprehensive level-II new-born care etc. a full-fledged KMC
program from 2021.
• The goal of KMC Program is to end preventable new-born
deaths due to prematurity & low birth weight through skin-to-
skin contact, breast feeding and early discharge from health
center.
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KMC in Nepal
• A total of 2,791 cases of sick newborns were
reported to be managed by Kangaroo Mother
Care (KMC) of which 31.7% for LBW, 23.6% for
preterm and 18.0% were managed for
hypothermia; remaining 26.7% for
preterm/LBW/ hypothermia.
• Most of the LBW newborns were from
Gandaki province (n=315) and hypothermia
were from Madhesh province (n=236)
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KMC in Nepal

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Prevention of Mother to Child Transmission of HIV (PMTCT)
• The transmission of HIV from an HIV-positive

mother to her child during pregnancy, labour,
delivery or breastfeeding is called mother-to-
child transmission (MTCT).
• In the absence of any interventions

transmission rates range from 15-45%. This rate
can be reduced to levels below 5% with
effective interventions.
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PMTCT
• The National Strategy has structured the
PMTCT programme around the following
comprehensive and integrated four prong
approach:

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PMTCT
1. Primary prevention of HIV transmission
2. Prevention of unintended pregnancies among
women living with HIV
3. Prevention of HIV transmission from women
living with HIV to their Children, and
4. Provision of Treatment, Care and Support for
women living with HIV and their children and
families.
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PMTCT
Services being provided

for PMTCT in Nepal:

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PMTCT
• HIV testing and counseling during ANC, labour and
delivery and postpartum
• Provision of ARV drugs to mothers and infected with
HIV infection
• Safer delivery practices
• Infant feeding information, counseling and support,
and
• Referrals to comprehensive treatment, care and
social support for mothers and families with HIV
infection.
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PMTCT
• In 2015, WHO released new guidelines on the
use of antiretroviral drugs (ARVs) for treating
and preventing HIV infection.
• The guidelines include recommendations for

providing lifelong antiretroviral treatment
(ART) to all pregnant and breastfeeding
women living with HIV for the prevention of
mother-to-child transmission (PMTCT).
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PMTCT
• The WHO 2015 guidelines recommend that
programmers follow Option B+ for PMTCT.
• Option B+ recommends providing lifelong ART to all

pregnant and breastfeeding women living with HIV
regardless of CD4 count or WHO clinical stage along
with prophylaxis treatment for their infants as well.
• ART should be maintained after delivery and

completion of breastfeeding for life.
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PMTCT
• Aiming at the elimination of mother to child
transmission (eMTCT), Nepal has taken a
major transformative measure in 071/72 and
adheres to Option B+

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PMTCT
• The roll out of the lifelong treatment adds the
benefits of triple reinforcing effectiveness to
the HIV response:
(a) help improve maternal health
(b) prevent vertical transmission; and
(c) reduce sexual transmission of HIV to sexual
partners.

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PMTCT
• With the collaboration of community based
organization, the government of Nepal
launched Community Based Prevention of
Mother to Children Transmission (CB‐PMTCT)
program in 2009 taking PMTCT services
beyond hospitals and making the services
accessible to pregnant women living in remote
areas.

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PMTCT
• Nepal has scaled up it PMTCT services in
recent years.
• The CB-PMTCT programme has been
expanded throughout the country.
• As a result of this scale up of PMTCT sites, the
number of women attending ANC and labour
who were tested and received results has
increased over the years.

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PMTCT
• Pursuant to its commitment to eliminate vertical
transmission of HIV among children by 2021, Nepal
has scaled up it PMTCT services in recent years.
• As a result of this scale up of PMTCT sites, the
number of women attending ANC and labour who
were tested and received results has increased over
the years.
• Despite this relative increase in uptake, the
coverage for PMTCT is still low (61%) against the
estimated pregnancies.
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PMTCT
• In addition, PMTCT services are being scaled up in
line with ART, HTC, STI and opportunistic infection
services for improving pregnant women’s with
HIV’s access to the continuum of care.
• Furthermore, links have been established between
PMTCT sites and key affected population-targeted
interventions, family planning, sexual and
reproductive health and counselling services.

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PMTCT
• Pursuant to its commitment to eliminate vertical
transmission of HIV among children by 2082/83
(2026), Nepal adheres to test and treat strategy and
promotes rapid ART initiation for all identified
pregnant women and breastfeeding mothers with
HIV, regardless of CD4 along with prophylaxis
treatment for their infants as well.
• Nepal has scaled up its PMTCT services in recent
years which led to an increased testing and
detection over years.
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eMTCT
• Elimination of Mother To Child Transmission of
HIV/Aids.
• eMTCT is a developing new concept.

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Early infant diagnosis
• Initiatives for the early infant diagnosis of HIV
in infants and children below 18 months of
age have been taken to identify infants early in
order to provide them with lifesaving ART, and
to facilitate early access to care and treatment
in order to reduce morbidity.

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Early infant diagnosis
Initiatives for Early Infant Diagnosis (EID) of HIV in
infants and children below 18 months of age have
been taken with the goals :
a) of identifying infants early in order to provide them
life-saving ART; and
b) of facilitating early access to care and treatment in
order to reduce morbidity. In this context, a
Deoxyribonucleic Acid (DNA) Polymerase Chain
Reaction (PCR) testing facility has been set up at
National Public Health Laboratory in Kathmandu.
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CB‐IMCI
• Community Based Integrated Management of

Childhood Illness (CB‐IMCI) Program is an
integrated package of child‐survival
interventions and addresses major childhood
killer diseases like Pneumonia, Diarrhoea,
Malaria, Measles and Malnutrition in 2
months to 5 years children in a holistic way.

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CB‐IMCI
• CB‐IMCI also includes management of

infection, Jaundice, Hypothermia and
counselling on breastfeeding for young infants
less than 2 months of age.
• With the implementation of this package

children are diagnosed early and treated
appropriately for major childhood illnesses at
the health facility and community level.

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CB‐IMCI
• At the community level, Health Workers are

the main vehicle of service delivery and FCHV
play a key supporting role to increase access
to services through counseling and community
mobilization.

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CB‐NCP
• MoHP has made newborn health a priority

and agreed to reinforce implementation of
newborn health care program at the
community level.
• Accordingly MoHP has initiated integrated

newborn health care package called
“Community Based Newborn Care Program
(CBNCP)” based on the National Neonatal
Health Strategy 2004.
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CB‐NCP
• The Community-based Newborn Care Package
is a set of neonatal care interventions to be
delivered through the existing government
system of facility-based health workers and
community based volunteers in Nepal.

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CB‐NCP
Objectives
• To prevent and manage newborn infection
• To prevent and manage hypothermia and LBW
babies
• To manage post-delivery asphyxia, and
• To develop an effective system of referral of
sick newborns

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CB - IMNCI
• CB‐NCP and CB‐IMCI have similarities in
interventions, program management, service
delivery and target beneficiaries.
• Both programs had duplicated interventions
like management of neonatal sepsis,
promotion of essential newborn care
practices, infection prevention, and
management of low birth weight.

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CB - IMNCI
• Although, FCHVs are doing very good
distribution and promotion of healthy
behaviors but they are poorly performing in
service delivery.
• Moreover, they were overburdened with
workloads and massive resource was used in
fragmented manner for the same purpose.

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CB - IMNCI
• Also, inequity in quality service delivery and
utilization are becoming the major challenges
in newborn and child health programming.
• Health governance issue is also affecting the
better functioning of the health system.
• Considering the management and
maintenance challenges in CB‐NCP and IMCI
program, MoH had decided to merge both the
program into CBIMNCI.
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CB‐IMNCI
• An integrated package of CBIMCI and CBNCP
(Community Bases Newborn Care Programme) is
being planned and is being implemented as CB -
IMNCI (Community-Based Integrated
Management of Newborn and Childhood Illness)
from 2071/72.
• In both of the programs (CB‐IMCI and CB‐NCP),
FCHVs were considered as front line health
services providers but quality and coverage of
service is very low.
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CB‐IMNCI
• CB-IMNCI is an integration of CB-IMCI and CB-NCP Program
as per the decision of MoHP on 2071/6/28 (October 14,
2015).
• This integrated package of child‐survival intervention
addresses the major problems of sick newborn such as
birth asphyxia, bacterial infection, jaundice, hypothermia,
low birth weight and counseling for breastfeeding.
• It also maintains its aim to address major childhood
illnesses like Pneumonia, Diarrhoea, Malaria, Measles and
Malnutrition among under 5 year’s children in a holistic
way.

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CB‐IMNCI
• In CB‐IMNCI program, FCHVs carry out health
promotional activities for maternal, new-born
and child health and dispensing of essential
commodities like distribution of iron, zinc,
ORS, chlorhexidine which do not require
assessment and diagnostic skills, and
immediate referral in case of any danger signs
that appear among sick new-borns and
children.
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CB‐IMNCI
• Health workers will counsel and provide health
services like management of non‐breathing cases,
low birth weight babies, common childhood
illnesses, and management of neonatal sepsis.
• Also, the program has provisioned for the post‐
natal visits by trained health workers through
primary health care outreach clinic.
• CB-IMNCI program has been implemented in all 77
districts.

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Facility-Based Integrated Management of
Childhood and Neonatal Illnesses in Nepal
• The Facility-Based Integrated Management of Neonatal
and Childhood Illnesses(FB-IMNCI) package has been
designed specially to address childhood cases referred
from peripheral level health institutions to higher
institutions.
• The package is linked strongly with the on-going
Community Based Integrated Management of Neonatal
and Childhood Illness (CB-IMNCI).
• The package is expected to bridge the existing gap in the
management of complicated neonatal and childhood
illnesses and conditions.
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• With the gradual implementation of this package,
further improvement in neonatal and child health
can be expected.
• This package addresses the major causes of
childhood illnesses with Emergency Triage and
Treatment (ETAT) practice at Health Facility and
thematic approach to common childhood illnesses
towards diagnosis and treatment especially new-
born care, cough, diarrhoea, fever, malnutrition
and anemia.
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• It aims to capacitate team of health workers at
district hospital with required knowledge and
skills to manage complicated under-five and
neonatal cases and to ensure timely and
effective management of referral cases.
• This training package is delivered to
paramedics and nursing staffs (3 days) and
doctors (6 days) at district, provincial and
federal hospitals.
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Development of CBIMNCI Program in Nepal
(year in parenthesis is in AD)

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Comprehensive New-Born Care Training
package in Nepal
• "Comprehensive Newborn Care Training Package
(For Level II Hospital Care)" was developed in
order to provide training to paediatricians, senior
medical officers and medical officers working in
the hospitals providing level II care services.
• The package is strengthening health system

supported by fully trained and skilled health
service providers in health facilities.
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package in Nepal
• This is a 6 days training package focused to help the
health workers to develop basic skills and
knowledge necessary for management of normal as
well as sick new-born.
• This package covers counselling, infection
prevention, care of normal new-born, feeding,
neonatal resuscitation, thermal protection, fluid
management, identification and management of
sick neonates, disorder of weight and gestation,
neonatal sepsis and common neonatal procedures.
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package in Nepal
• The training started from 19th December,
2016 and is conducted in each Province every
year.
• National Health Training Centre has developed
Comprehensive New-born Care Training (Level
II) package in 2017 and has been conducting
training for Nurses in coordination with Family
Welfare Division.

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Free New-Born Care Services in Nepal
• Since 2016, the Government of Nepal (GoN) has
made provisions on treating sick newborn free of
cost through all tiers of its health care delivery
outlets.
• Aim of this program is to prevent any sort of

deprivation to health care services of the newborn
due to poverty. Based on the treatment services
offered to the sick-newborn, the services are
classified into 3 packages: A, B and C.
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• The new born corners in health posts and PHCCs
offer Package ‘A’, district hospitals with Special
Newborn Care Unit (SNCU) offer Package ‘B’,
provincial and other tertiary hospitals offer
Neonatal Intensive Care Unit (NICU) services under
Package ‘C’.
• The government has made provisions of required

budget and issued directives to implement the free
newborn care packages throughout Nepal.
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• The goal of the Free Newborn Care Service
Package is to achieve the sustainable development
goal to reduce newborn mortality through
increased access of the newborn care services.
• The program includes the provision of disbursing

Cost of Care to respective health institutions
required for providing free care to inpatient sick
New-born.

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Goals of IMNCI & New-born
Care program of Nepal
• Goal
Improve newborn child survival and ensure
healthy growth and development.
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Targets of IMNCI & New-born
• Targets: Target for reduction of NMR, U-5MR
& Stillbirths by NHSS, NENAP, SDGs

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Targets of IMNCI & New-born

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Objectives of IMNCI & New-born
• To reduce neonatal morbidity and mortality by
promoting essential New-borncare services &
managing major causes of illness
• To reduce childhood morbidity and mortality
by managing major causes of illness among
under 5 years of age children

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Strategies of IMNCI & New-born
1. Quality of care through system strengthening and
referral services for specialized care
2. Ensure universal access to health care services for
newborn and under 5 years of children
3. Capacity building of health service providers and
FCHVs
4. Increase service utilization through demand
generation activities
5. Promote decentralized and evidence-based
planning and programming
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Major strategic interventions included in
CB‐IMNCI Program
Newborn Specific Interventions
• Promotion of birth preparedness plan
• Promotion of essential newborn care practices and
postnatal care to mothers and newborns
• Identification and management of non‐breathing
babies at birth
• Identification and management of preterm and low
birth weight babies
• Management of sepsis among young infants (0‐59
days) including diarrhea
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CB‐IMNCI Program
Child Specific Interventions
• Case management of children aged between
2‐59 months from 5 major childhood killer
diseases (pneumonia, diarrhoea, malnutrition,
measles and malaria)

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CB‐IMNCI Program
Cross Cutting Interventions:
• Behaviour change communications for healthy
pregnancy, safe delivery and promote
personal hygiene and sanitation
• Improved knowledge related to Immunization
and Nutrition and care of sick children
• Improved interpersonal communication skills
of Health Service Providers & FCHVs
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CB‐IMNCI Program
Capacity enhancement & quality
assurance
• Onsite coaching (guidelines
development/revision, coach development,
coaching &mentoring)
• Routine Data Quality Assessment

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Key CB‐IMNCI Program Monitoring
Indicators
1. % of Institutional delivery
2. % of newborn who had chlorhexidine gel applied
immediately after birth (within one hour)
3. % of infants (0‐2 months) with PSBI receiving complete
dose of Gentamycin injection
4. % of under 5 children with pneumonia treated with
antibiotics
5. % of under 5 children with diarrhoea treated with ORS
and Zinc
6. Stock out of the 5 key CB-IMNCI commodities at health
facility (ORS, Zinc, Gentamicin, Amoxicillin/Cotrim, CHX)
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Vision 90 by 30
• CB-IMNCI program has a vision to provide
targeted services to 90% of the estimated
population by 2030
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CB –IMNCI PROGRAM VISION
219
SWOT Analysis of IMNCI Program

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STRENGTH:
• Covers both community and facility based
management of the common newborn and
childhood illnesses

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WEAKNESSES:
• Lack of dedicated human resource in Hospital
for SNCU/NICU/KMCU
• Inadequate IEC and BCC activities as compared
to the approved program implementation
guideline, so as to improve the demand of CH
services
• Lack of equipment to deliver new-born and
child health services at service delivery points
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OPPORTUNITY:
• Engagement of the private sector

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THREATS:
• No provision of CBIMNCI dedicated officer at
province & municipalities
• Difficulties to implement free new-born care
guideline as expected
• Frequently stock-outs of essential commodities
in districts, municipality and community level.
• Inappropriate referral mechanism

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WHAT IS CHILD SURVIVAL?
• Concentrated efforts by governments, the

United Nations, organizations, and
communities to use effective, low-cost
solutions to protect children from illness
during their first five years of life.

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Child Survival Strategies
• Child survival programs tend to focus on the main
causes of morbidity and mortality, such as diarrhea,
acute respiratory infections (ARI), malnutrition,
malaria, and the six vaccine-preventable childhood
diseases.
• In addition, such programs may target related

issues, including maternal and newborn care, child
spacing, STI/HIV/AIDS prevention and care, and
other infectious diseases (e.g., tuberculosis).
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• The WHO/UNICEF Regional Child Survival
Strategy focuses on the implementation of an
Essential package for child survival.
• This package is composed of the following:

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Child Survival Strategies (WHO/UNICEF)
1. Skilled attendance during pregnancy, delivery
and the immediate postpartum
2. Care of the newborn
3. Breastfeeding and complementary feeding
4. Micronutrient supplementation
5. Immunization of children and mothers
6. Integrated management of sick children
7. Use of insecticide-treated bednets (in malarious
areas)
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1. SKILLED ATTENDANCE DURING PREGNANCY,
DELIVERY AND THE IMMEDIATE
POSTPARTUM:
Important child survival interventions provided
through skilled attendance during pregnancy
include:

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1. antenatal care with a haemoglobin estimate
for maternal anaemia, urine protein and blood
pressure monitoring for prevention and
management of pre-eclampsia and eclampsia
2. prevention and treatment of malaria,

counselling for breastfeeding, preparation of a
birth plan, detection of complications, and
early referral of complications.
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3. At delivery and in the immediate postpartum
period it is necessary to have a skilled
attendant who can ensure a clean delivery,
use a partogram and delivery kit, recognize
complications, and refer, if necessary.

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2. CARE OF THE NEWBORN:
Low-cost, evidence-based interventions that
should be available as part of national
newborn care guidelines include :

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1. clean cord care,
2. newborn resuscitation,
3. newborn temperature management,
4. initiation of breastfeeding within one hour of
delivery

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5. weighing the baby to assess for low birth-
weight,
6. kangaroo mother care for low birth-weight
babies,
7. case management of neonatal pneumonia
and sepsis.
8. Postnatal care also needs to be ensured.

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3. BREASTFEEDING AND COMPLEMENTARY
FEEDING:
• Improved infant and young child feeding
practices need to be protected, promoted and
supported with exclusive breastfeeding up to 6
months of age, continued breastfeeding up to
2 years of age or beyond, and adequate and
safe complementary feeding from 6 months
onwards.
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4. MICRONUTRIENT SUPPLEMENTATION
1. For the reduction of child mortality, the most
important micronutrient supplementation is
Vitamin A, given every six months for
children aged 6-59 months.

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2. Micronutrient supplementation of the mother,
including iron and folic acid provided through
antenatal care and Vitamin A given in the postnatal
period may be determined by national guidelines.
3. Improved diets including fortification and

supplementation of food are necessary to achieve
appropriate micronutrient levels for children and
mothers.

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5. IMMUNIZATION OF CHILDREN AND MOTHERS
1. Vaccinating children with measles, tetanus,
diphtheria, pertussis, polio, BCG and
hepatitis B vaccines is part of the routine
Expanded Programme on Immunization
(EPI) schedule.
2. To ensure protection among newborns
against tetanus, the mother should have
received two doses of Td vaccine.
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3. In some countries and areas, additional
vaccines may be available through the routine
EPI schedule.
4. Vitamin A and deworming may also be

delivered with immunization, and use of
insecticide-treated bednets should be
promoted during immunization sessions.

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6. INTEGRATED MANAGEMENT OF SICK
CHILDREN:

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1. Management of pneumonia, diarrhoea and malaria
requires an integrated approach.
2. Assessing the whole child during a consultation will

allow the identification and treatment of all major
conditions such as pneumonia, diarrhoea, malaria
and other febrile conditions as well as
undernutrition.
3. It will also prompt referral as necessary.

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4. A continuum of care must be emphasized where case
management occurs in the community, at first-level
health facilities and at referral hospitals.
5. Different combinations of interventions will be

available at each delivery point.
6. Referrals to hospitals are necessary for children with

severe pneumonia, diarrhoea and malaria as well as
with other severe conditions.
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Continuum of Care in Child Survival
Strategies
Care of the mother, safe delivery –
Continuum of Care
immediate newborn care

Prevention of illness and care of the
newborn in the first month of life
Prevention of childhood illness and
integrated management of childhood
illness

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Continuum of Care in Child Survival
Strategies
• Home
Start with action at home
• Community
• Outreach
• First Level Health Facility
• Referral Facility

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7. USE OF INSECTICIDE-TREATED BEDNETS:
• In malarious areas, insecticide-treated
bednets should be available as a preventive
intervention for malaria.
• For vulnerable populations living in remote
areas, long-lasting insecticide-treated nets
have an advantage over insecticide dipping of
conventional nets.

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Actions that strengthen the essential
package of child survival strategies
1. IMPROVEMENTS IN WATER, SANITATION AND
THE ENVIRONMENT
2. BIRTH SPACING
3. PROMOTING GENDER EQUALITY,
EMPOWERMENT OF WOMEN AND
WOMEN’S EDUCATION
4. PREVENTION OF MOTHER-TO-CHILD
TRANSMISSION OF HIV

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Strategic approaches for child survival
1. IMPROVING LEADERSHIP AND GOVERNANCE

2. CONSOLIDATING PARTNERSHIPS
3. IMPROVING EFFICIENCY AND QUALITY OF
SERVICE DELIVERY
4. DELIVERING ESSENTIAL INTERVENTIONS AT
THE COMMUNITY LEVEL

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Strategic approaches for child survival
5. SERVICE DELIVERY AT THE HEALTH FACILITY

LEVEL
6. ENGAGING AND EMPOWERING FAMILIES AND
COMMUNITIES
7. ENSURING HEALTH CARE FINANCING
SUPPORT FOR CHILD SURVIVAL

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Surveillance
• Surveillance is the ongoing systematic
collection, recording, analysis, interpretation,
and dissemination of data reflecting the
current health status of a community or
population.

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Child Health Surveillance
• ‘Child health surveillance is the systematic and
ongoing collection, analysis, and
interpretation of indices of child health,
growth, and development in order to identify,
investigate and, where appropriate, correct
deviations from predetermined norms’ (Stone
1990).

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• Individual surveillance focuses on a particular
child, and will include gathering data from
screening tests, physical examinations,
discussions with parents and other caregivers,
etc. This is also sometimes referred to as
clinical surveillance.

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• Population surveillance focuses on groups or
entire populations, and enables observation of
changes and trends at a public health level.
This is also sometimes referred to as
monitoring.

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• A surveillance technique which consists of
monitoring and
assessing a baby's physical defects, if present,
as well as assessing development and progress
in the first few years of life.

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• The principles of Child Health Surveillance are:
 to identify and treat both physical problems

and developmental delay as early as possible;

 to minimise disability and impairment by
early and effective intervention;

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 to provide support and resources for children
with identified conditions;
 to offer health information to promote
physical and mental health and well being;
 to identify and support vulnerable children
and their families.

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• Surveillance aims to optimise the health of
children through the ongoing overview of the
physical, social and emotional health and
development of all children.
• It includes:

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1. the measurement and recording of physical
growth monitoring of developmental progress
2. the administration of screening tests
3. offering and arranging intervention when
necessary
4. prevention of disease by immunisation and other
means
5. providing information and support to parents
6. health education
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• It should be noted that child health
surveillance:
 is initiated by health professionals but involves
partnership with parents
 involves whole populations of children
 comprises primary, secondary and tertiary
prevention activities

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Child’s Rights
• The concept of child rights goes back to the
beginning of the 20th century when, in 1924,
the League of Nations adopted the Geneva
Declaration on the Rights of the Child.
• This was the first time when the existence of

rights specific to children was recognized and
affirmed by the international community.

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Child’s Rights
• The international legal framework on the
rights of the child continued to develop with
the establishment of the United Nations in
1945.

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Child’s Rights
• The Universal Declaration of Human Rights (UDHR)
of 1948 recognizes that childhood is entitled to
special care and assistance.
• The UN General Assembly Declaration on the

Rights of the Child, 1959, encompasses a much
wider perspective on children’s rights including the
right to freedom from discrimination, the right to a
name and a nationality and the right to education,
health care and special protection.
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Child’s Rights
• The UN Convention on the Rights of the Child
(UNCRC) adopted by the UN General
Assembly in 1989 is the first comprehensive
and legally binding treaty on the rights of the
child.

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Child’s Rights
• The convention was passed by the UN general
assembly on November 20, 1989 and
implemented on 2 September 1990.
• Nepal ratified this convention

unconditionally on 14 September 1990. The
convention has 54 articles.

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Convention on Child Rights 1989
• The convention contains definition of child,
provision against any discrimination against
children, welfare of children, enforcement of
rights, guidance to parents and management
for capacity development of children.

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• The convention also has provisions about life
and development, name and nationality,
protection of identity, status of the children
after divorce of parents, family reunion, illegal
transfer and non-return of children.
• The convention protects the children’s right to

expression, ideology, wisdom and religion,
right to association, among others.
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• The convention also has provisions regarding
right to privacy, right to information, parents’
liabilities, protection against misconduct and
neglect, protection of children without
families.

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• Similarly, the convention has outlined process
for adoption and prioritized the issues related
with refugee children and differently abled
children and related with health and health
facilities of the children, periodic evaluation of
nutrition, social security, life standard,
education and the objectives of education.

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• The convention also deals with the issues
related with children of minorities, leisure,
rest and cultural activities, child labor, drug
addition, sexual exploitation, trafficking,
bargain, kidnap, other forms of exploitation,
torture, loss of freedom, armed conflict, care
during rehabilitation, juvenile jurisprudence
and others.

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Child’s Rights in Nepal
• Nepal has made headway in recognizing rights of the
child, developing legal framework, establishing
institutional mechanisms, and formulating appropriate
national plans and policies on child rights.
• Despite many socio-economic and political challenges,

Nepal has made considerable progress in child health
and child education sectors as per the indicators set by
Millennium Development Goals (MDGs).

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Some National Laws and Plans on Child
Rights and Child Protection
• Children’s Act 1992

• Child Labour (Prohibition and Regularisation) Act,
2000
• Human Trafficking and Transportation (Control) Act,
2064 (2007)
• Legal Provisions regarding the Adoption of Child, 2067
(2011)
• Juvenile Justice Procedural Rules, 2063 (2006)
• National Plan of Action on Children (2004/05-
2014/15)
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Article 22: Rights of Child in Nepal
(1) Every child shall have the right to his/her own
identity and name.
(2) Every child shall have the right to be

nurtured, to basic health and to social
security.

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(3) Every child shall have the right to protection
against physical, mental or any other forms of
exploitation. Any such act of exploitation shall
be punishable by law, and the child so treated
shall be compensated in a manner as
determined by law.

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(4) Helpless, orphan, mentally retarded, conflict
victims, displaced, vulnerable and street
children shall have the right to special
privileges from the State to secure their
future.
(5) No minor shall be employed in factories,
mines or in any other such hazardous work, or
shall be used in the army, police or in conflicts.

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Social Problems in Children
1. Homeless Children
2. Orphaned or abandoned Children
3. Children whose parents cannot or are not
able to take care of them
4. Children separated from parents
5. Migrant and refugee children
6. Street Children

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7. Working children
8. Trafficked children
9. Children in bondage
10. Children in prostitution
11. Children of sex workers /prostitutes / sexual
minorities

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12. Children of prisoners
13. Children affected by conflict
14. Children affected by natural disasters
15. Children affected by HIV I AIDS
16. Children suffering from terminal diseases

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17. The girl child
18. Children with disabilities and related special
needs
19. Children belonging to the ethnic and religious
minorities, and other minority communities,
20. Children in institutional care,
21. Children in conflict with law (those who commit
crimes)
22. Children who are victims of crime
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• Social problems in children can affect all
domains of development - physical,
psychological, emotional, behavioural, and
social - all of which are interrelated.

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CHILD MALTREATMENT
KEY FACTS
• A quarter of all adults report having been physically abused as
children.
• One in 5 women and 1 in 13 men report having been sexually abused
as a child.
• Consequences of child maltreatment include impaired lifelong
physical and mental health, and the social and occupational
outcomes can ultimately slow a country's economic and social
development.
• Preventing child maltreatment before it starts is possible and
requires a multisectoral approach.
• Effective prevention programmes support parents and teach positive
parenting skills.
• Ongoing care of children and families can reduce the risk of
maltreatment reoccurring and can minimize its consequences.
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Child Abuse
• Kempe and Kempe (1978) have defined child
abuse as “a condition having to do with those who
have been deliberately injured by physical attack”.
• Burgess (1979) child abuse refers to “any child who

receives non-accidental physical and psychological
injury as a result of acts and omissions on the part
of his parents or guardians or employers…”

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Child Abuse
• The concept of child abuse has been
broadened to include not only physical
violence, but sexual abuse , mental and
emotional maltreatment, neglect, deprivation
and lack of opportunity.
• The consequences of physical battering -
death, blindness, mental and emotional
retardation, stunting of growth - is only one
part of the whole picture of child abuse.
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Child Abuse
• Some contributory factors of child abuse are
poverty, alcohol and other drug abuse,
loneliness, immaturity and a host of other
factors. Many causes are embedded in the
family and in its function of child rearing.

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Health Effects of Child Abuse
• Physical Health Consequences: Abusive Head
Trauma, Impaired brain development, poor
physical health
• Psychological Consequences: Difficulties

during infancy, poor mental and emotional
health, cognitive difficulties, social difficulties

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Health Effects of Child Abuse
• Behavioural Consequences: Difficulties during
adolescence, Juvenile delinquency and adult
criminality, Alcohol and other drug abuse,
Abusive behavior, etc.

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Street Children
• A large number of children live and work on the
streets, a high proportion without any family
support, particularly in the megacities of the
developing world.
• Children from rural villages and districts end up on

city streets as a result of poverty, broken families,
physical and mental abuse in the family,
abandonment, helplessness, and desire to live in
the city.
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Street Children
• They are at high-risk of malnutrition,
tuberculosis, STDs including HIV, parasite and
worm infestation and skin diseases. Both sexes
are highly vulnerable to drug abuse,
prostitution and criminal exploitation .

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Street Children
• Street children face hunger, lack of health and
education facilities, lack of opportunity for skills
development, physical and sexual exploitation by
elder and former street children, drug abuse, etc.
• It is also reported that as they grew up they face

difficulties in making a livelihood and,
consequently, became involved in immoral and
illegal activities, contributing to social disorder.
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Street Children
• Most street children describe major losses in
their lives. Many have lost family members
through diseases, natural or manmade
disasters, or may be by product of war and
riots.

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Street Children
• Often the lives of street children are intimately
entwined with the illicit drug industry. Street
children are used in the production and
marketing of cocaine and the trafficking of
cannabis and heroin.

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Refugee and Displaced Children
• Refugee and internally displaced children face
many risks, given the violence and uncertainty
surrounding both their flight and their lives in
the country and/or place of asylum.
• They may become separated from their

families, lose their homes and find themselves
living in poor conditions that jeopardize their
health and education.
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• The loss of family protection, and inadequate
resources to address the needs and challenges that
refugee and internally displaced children face, can
leave them at significant risk of recruitment by armed
groups and forces, abuse and sexual exploitation .
• Girls are especially at risk of abduction, trafficking

and sexual violence, including rape used as a weapon
of war. Orphaned children are much more vulnerable
to protection violations.
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• Children living on their own are at much
greater risk of abuse and exploitation.
• Assessments by the International Labour

Organization (ILO) have found that orphaned
children are much more likely than non-
orphans to be working in commercial
agriculture , as street vendors, in domestic
service and in the sex trade .
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Child Labour and Child Exploitation
• There are several reasons for children joining the
workforce: social reasons, economic reasons,
psychological reasons, inadequate policy and
regulatory system, lack of comprehensive social
and developmental infrastructure etc.
• Complex relationship exists among the various

causes as many of these reasons ate interwoven to
one another. Often one cause is an effect of
another
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• A sizeable number of growing children of poor
socioeconomic class especially in rural areas
are known to be inducted as child labour.
• Studies have shown that labour at very young

ages can have dire consequences on the
child's development, both physical and
mental.

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• The employers of children as laborer even
argue that they are providing protection and
helping poor children, and therefore, they feel
good about it.
• They fail to realize that such immediate

‘favor’ results in destruction of childhood

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• Child labourers always had lower growth and
health status compared to their non-working
counterparts, besides exposure to
occupational hazards at a very young stage in
their lives. Africa and Asia dominate the data
on child labour. The scenario has not changed
much to the present time .

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• Children in domestic service are the most
invisible child labourers. Their work is
performed within individual homes, removed
from public scrutiny and their conditions of
life and labour are entirely dependent on the
whims of their employers.

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• The number of children involved in domestic service
around the world is unquantifiable because of the
hidden nature of the work, but it certainly runs into
millions.
• Many of these children are girls, and in many

countries domestic service is seen as the only
avenue of employment for a young girl, though in
some places, such as Nepal and South Africa, boys
are more likely to be domestic workers than girls .
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• Children exploited in domestic service are
generally paid little or nothing over and above
food and lodging. In addition, children in
domestic service are especially susceptible to
physical and psychological harm.

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• Many are forced to undertake tasks that are
completely inappropriate for their age and
physical strength.
• Another form of forced labour is debt

bondage, whatever the origin of the debt, it
leaves children under complete control of a
money lender in a state little distinguishable
from slavery.
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• The consequences and social costs of child
labor on the affected children are very high. It
impairs their physical, mental and moral
health at a very crucial and critical stage of life
that leaves permanent consequences.
• Even more destructive to quality of life in

long-term is permanent damage caused to the
social development of the child.
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• Child labour is rooted in poverty,
unemployment and lack of education.
• It is not feasible to abolish child labour entirely

in the present context, but it is expedient to
protect such children against abuse,
exploitation and health hazards, and regulate
the conditions of work in occupations where
child labour is permitted.
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Child Trafficking
• Trafficking of children takes many different
forms. Some children are forcibly abducted,
others are tricked and still others opt to let
themselves be trafficked by promise of
earnings, but not suspecting the level of
exploitation they will suffer at the other end of
the recruiting chain .

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Child Trafficking
• Trafficking always involves journey, whether
within the country or across the international
border.
• The relocation takes children away from their

families, communities and support net-work,
leaving them isolated and utterly vulnerable to
exploitation.

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Child Trafficking
• Children are also trafficked into plantations
and mines, and in those countries affected by
conflict, they are directly abducted by militias.
• In East Asia and Pacific, most trafficking is into

child prostitution, though some children are
also recruited for industrial and agricultural
work.

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Child Trafficking
• In South Asia, trafficking forms most of
immense child labour problem in the sub-
continent, often related to debt bondage.
• In addition, significant number of children are

trafficked for other purposes, including into
prostitution , carpet and garment factories,
construction projects and begging.

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Child Trafficking
• Girl trafficking is one of the major challenges facing
Nepal. Innocent Nepali women and girls of different
castes and communities from different regions of
Nepal are taken out of the country and forced into
prostitution.
• Many women and girls who are trafficked contract a

deadly virus called HIV/AIDS. Many people have
never heard of HIV/AIDS and do not know what it is
or how they can contract the illness.
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Steps to be taken to control social
problems in children
1. Strengthening the capacity of families and
communities to care for and protect children .
2. Government commitment to child protection
by providing budgetary support and social
welfare policies targeted at the most excluded
and invisible children.
3. Ratification and implementation of
legislation , both national and international,
concerning children's rights and protection.
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4. Prosecution of perpetrators of crimes against
children, and avoidance of criminalizing child
victims.
5. An open discussion by civil society and the media
of attitudes, prejudices, beliefs and practices that
facilitate or lead to abuses.
6. Ensuring that children know their rights, are
encouraged to express them and are given vital life
skills and information to protect themselves from
abuse and exploitation.
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7. Availability of basic social services to all
children without discrimination.
8. Monitoring, transparent reporting and

oversight of abuses and exploitation.

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9. The key to building the protective environment
is the responsibility of members of the society,
by ensuring that children are not exploited.
10. While families and the State have the primary

responsibility for protecting children, on-going
and sustained efforts by individuals and
organizations at all levels, are essential to break
patterns of abuse .
cal College

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CHILD HEALTH

MBBS 1ST YEAR

Dr Niki Shrestha. Assoc. Prof. Chitwan

Dr Niki Shrestha. Assoc. Prof. Chitwan Medi 3

Dr Niki Shrestha. Assoc. Prof. Chitwan Medi 4

Dr Niki Shrestha. Assoc. Prof. Chitwan

Dr Niki Shrestha. Assoc. Prof. Chitwan Medi 7

Dr Niki Shrestha. Assoc. Prof. Chitwan Medi 8

Dr Niki Shrestha. Assoc. Prof. Chitwan Medi 9

Dr Niki Shrestha. Assoc. Prof. Chitwan Medi 10

• The Sustainable Development Goals (SDGs) adopted by

• Target 3.2.1 is closely linked with target 3.1.1,

Dr Niki Shrestha. Assoc. Prof. Chitwan Medi 12

• Meeting the SDG target would reduce the

Dr Niki Shrestha. Assoc. Prof. Chitwan Medi 13

• It includes the sub- areas of maternal health,

(b) promotion of reproductive health ; and

(c) promotion of the physical and psychological

The ultimate objective of MCH services is life-

• The period of development of foetus in mother

• During this period, the foetus obtains all the

• Certain diseases and conditions of the mother

Dr Niki Shrestha. Assoc. Prof. Chitwan

• At least up to the age of 6 to 9 months, the

• The mental and social development of the

• The mother is also the first teacher of the

• It is for these reasons, the mother and child

Dr Niki Shrestha. Assoc. Prof. Chitwan

• The current trend in many countries is to

Dr Niki Shrestha. Assoc. Prof. Chitwan

Dr Niki Shrestha. Assoc. Prof. Chitwan Medi 23

Dr Niki Shrestha. Assoc. Prof. Chitwan

Dr Niki Shrestha. Assoc. Prof. Chitwan

• Consists of taking care of not only the mother

Dr Niki Shrestha. Assoc. Prof. Chitwan

Dr Niki Shrestha. Assoc. Prof. Chitwan

Dr Niki Shrestha. Assoc. Prof. Chitwan

Dr Niki Shrestha. Assoc. Prof. Chitwan

Delivery care services in Nepal, include:

Dr Niki Shrestha. Assoc. Prof. Chitwan Medi 32

Dr Niki Shrestha. Assoc. Prof. Chitwan Medi 33

• In FY 2079/80, 79.8% of the deliveries were attended

• Three provinces- Bagmati (98.5%), Lumbini (92.7%),

• Notably there is consistent improvement in Karnali,

Dr Niki Shrestha. Assoc. Prof. Chitwan

Dr Niki Shrestha. Assoc. Prof. Chitwan

Dr Niki Shrestha. Assoc. Prof. Chitwan

Dr Niki Shrestha. Assoc. Prof. Chitwan

• This combined area of responsibility is also

Dr Niki Shrestha. Assoc. Prof. Chitwan

• This is when the mother and child

Dr Niki Shrestha. Assoc. Prof. Chitwan

• At the time of birth, a baby's chance of

All babies should receive the following:

Dr Niki Shrestha. Assoc. Prof. Chitwan

Dr Niki Shrestha. Assoc. Prof. Chitwan

Dr Niki Shrestha. Assoc. Prof. Chitwan

Dr Niki Shrestha. Assoc. Prof. Chitwan

Dr Niki Shrestha. Assoc. Prof. Chitwan

Dr Niki Shrestha. Assoc. Prof. Chitwan