Improving infant care in rural communities in Nepal

Bhagwati was born at home in a village of Morang District, Nepal, the third child of Sisa and Shiva. Neither of her parents have had any formal education, nor do they own land. Her father works as a day laborer, weighing grains for farmers. They are members of a disadvantaged community, referred to locally as Musahars.

Bhagwati was not small at birth, nor was she premature. She was a healthy baby, exclusively breast fed, but on the 26th day of her life, she developed a cough and fever. Her parents consulted a traditional healer, a dhami or phuk phak garne manche, who came to their home to treat her, but she did not improve.

On day 28, Sisa took Bhagwati to an EPI/vaccination clinic conducted through the local sub-health post. Fortunately, the local village health worker, Shankar, who administers the vaccinations, had recently attended a training session for the new neonatal health program Navajat Shisu Swasthya Karyakram.

A healthy Bhagwati at 7 months of age with her mother, Sisa

The Morang Innovative Neonatal Intervention (also referred to as MINI) program, is implemented by the Morang District Public Health Office and JSI Research & Training Institute, Inc., with funding from the Bill & Melinda Gates Foundation, through Save the Children/USA Saving Newborn Lives.

MINI is currently implemented in 21 of the 65 village development committees in Morang District, covering 300,000 people (approximately 44 percent of the total population). Plans for expansion to the remainder of the district will be developed in early 2006.

Through the program, female community health volunteers are trained to conduct health assessments, initiate treatment, and call for the village health or maternal child health workers to provide antibiotics.

As a village health worker, Shankar is trained to examine newborns, and if any one of 10 danger signs of neonatal infection is present, he can initiate treatment with antibiotics such as oral cotrimoxazole tablets and gentamicin (genta) injections.

When Shankar gave Bhagwati a BCG vaccination for tuberculosis, she did not cry—weak or absent cry being one of the possible indicators for neonatal infection. Because he was very busy in the clinic, Shankar informed Sisa about the danger signs of neonatal infection and asked her to bring Bhagwati to the sub-health post again the next day for further examination.

The next day, both an auxiliary health worker and Shankar examined Bhagwati. Bhagwati exhibited three danger signs—a high respiratory rate, a weak cry and weak suckling.

The sub-health post staff treated Bhagwati and gave her mother information about essential newborn care, how to give oral medication at home, and advised her to return quickly if the baby's condition worsened. By the third day, Bhagwati's condition had greatly improved, although she still had a cough. Shankar made visits to Bhagwati's home and gave her the remaining genta injections each day.

Sixteen days after completing the first course of treatment, Bhagwati again developed a cough and her mother immediately took her to the SHP for examination. There, she received a second full course of treatment with follow-up care at home, this time from a maternal child health worker.

Bhagwati is now almost seven months old. She was exclusively breastfed for six months and her mother has just started to introduce rice and lentils, while continuing to breastfeed.

Bhagwati has had her DPT and polio vaccinations and just had her first dose of high dose vitamin A during the semiannual distribution in mid-October. She is a very active and bright little girl, whose family has now developed faith in the local health post and their staff. They speak highly of the care they have received and are pleased that services are being provided in their settlement. For their family, it was important that the services were provided free of charge. In the last two months, Sisa and Shiva have enrolled their two older children, a six-year old girl and a five-year old boy, in the local school.

Neighbors and other families are well aware of the treatment and attention that Bhagwati has received from the health post staff and they have also learned about essential newborn care, danger signs and where to seek advice and treatment. The village health worker is popular with local families.

The sub-health post staffs are proud that they are now able to manage many of the neonatal infections in the community and that the program is so well received. The staffs of the district public health office are also supportive and are involved in every aspect of the program implementation, with the intention of incorporating this program into the existing community-based integrated management of childhood illness (IMCI) program, after the initial phase.