Neonatal health in Nepal: analysis of absolute and relative inequalities and impact of current efforts to reduce neonatal mortality

Background: Nepal has made substantial progress in reducing
under-five mortality and is on track to achieve Millennium
Development Goal 4, but advances in neonatal health are less
encouraging. The objectives of this study were to assess relative
and absolute inequalities in neonatal mortality over time, and to
review experience with major programs to promote neonatal health.
Methods: Using four nationally representative surveys conducted in
1996, 2001, 2006 and 2011, we calculated neonatal mortality rates
for Nepal and for population groups based on child sex,
geographical and socio-economic variables using a true cohort log
probability approach. Inequalities based on different variables and
years were assessed using rate differences (rd) and rate ratios
(rr); time trends in neonatal mortality were measured using the
annual rate of reduction. Through literature searches and expert
consultation, information on Nepalese policies and programs
implemented since 1990 and directly or indirectly attempting to
reduce neonatal mortality was compiled. Data on timeline, coverage
and effectiveness were extracted for major programs. Results: The
annual rate of reduction for neonatal mortality between 1996 and
2011 (2.8 percent per annum) greatly lags behind the achievements
in under-five and infant mortality, and varies across population
groups. For the year 2011, stark absolute and relative inequalities
in neonatal mortality exist in relation to wealth status (rd =
21.4, rr = 2.2); these are less pronounced for other measures of
socio-economic status, child sex and urban-rural residence,
ecological and development region. Among many efforts to promote
child and maternal health, three established programs and two pilot
programs emerged as particularly relevant to reducing neonatal
mortality. While these were designed based on national and
international evidence, information about coverage of different
population groups and effectiveness is limited. Conclusion:
Neonatal mortality varies greatly by socio-demographic variables.
This study clearly shows that much remains to be achieved in terms
of reducing neonatal mortality across different socio-economic,
ethnic and geographical population groups in Nepal. In moving
forward it will be important to scale up programs of proven
effectiveness, conduct in-depth evaluation of promising new
approaches, target unreached and hard-to-reach populations, and
maximize use of financial and personnel resources through
integration across programs.