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Objective To determine home based newborn care practices in rural Nepal in order to inform strategies to improve neonatal outcome. Design Cross sectional, retrospective study using structured interviews. Setting Makwanpur district, Nepal. Participants 5411 married women aged 15 to 49 years who had given birth to a live baby in the past year. Main outcome measures Attendance at delivery, hygiene, thermal care, and early feeding practices.Results 4893 (90%) women gave birth at home. Attendance at delivery by skilled government health workers was low (334, 6%), as was attendance by traditional birth attendants (267, 5%). Only 461 (8%) women had used a clean home delivery kit, and about half of attendants had washed their hands. Only 3482 (64%) newborn infants had been wrapped within half an hour of birth, and 4992 (92%) had been bathed within the first hour. 99% (5362) of babies were breast fed, 91% (4939) within six hours of birth. Practices with respect to colostrum and prelacteals were not a cause for anxiety. Conclusions Health promotion interventions most likely to improve newborn health in this setting include increasing attendance at delivery by skilled service providers, improving information for families about basic perinatal care, promotion of clean delivery practices, early cord cutting and wrapping of the baby, and avoidance of early bathing.

Background: Perinatal (stillbirths and fi rst week neonatal deaths) and neonatal (deaths in the fi rst 4 weeks) mortality rates remain high in developing countries like Nepal. As most births and deaths occur in the community, an option to ascertain causes of death is to conduct verbal autopsy. Objective: The objective of this study was to classify and review the causes of stillbirths and neonatal deaths in Dhanusha district, Nepal. Materials and Methods: Births and neonatal deaths were identifi ed prospectively in 60 village development committees of Dhanusha district. Families were interviewed at six weeks after delivery, using a structured questionnaire. Cause of death was assigned independently by two pediatricians according to a predefi ned algorithm; disagreement was resolved in discussion with a consultant neonatologist. Results: There were 25,982 deliveries in the 2 years from September 2006 to August 2008. Verbal autopsies were available for 601/813 stillbirths and 671/954 neonatal deaths. The perinatal mortality rate was 60 per 1000 births and the neonatal mortality rate 38 per 1000 live births. 84% of stillbirths were fresh and obstetric complications were the leading cause (67%). The three leading causes of neonatal death were birth asphyxia (37%), severe infection (30%) and prematurity or low birth weight (15%). Most infants were delivered at home (65%), 28% by relatives. Half of women received an injection (presumably an oxytocic) during home delivery to augment labour. Description of symptoms commensurate with birth asphyxia was commoner in the group of infants who died (41%) than in the surviving group (14%). Conclusion:The current high rates of stillbirth and neonatal death in Dhanusha suggest that the quality of care provided during pregnancy and delivery remains sub-optimal. The high rates of stillbirth and asphyxial mortality imply that, while efforts to improve hygiene need to continue, intrapartum care is a priority. A second area for consideration is the need to reduce the uncontrolled use of oxytocic for augmentation of labour.

Inability to reduce neonatal and maternal mortality in poor countries is sometimes blamed on a lack of contextual knowledge about care practices and care-seeking behavior. There is a lack of knowledge about how to translate formative research into effective interventions to improve maternal and newborn health. We describe the findings of formative research and how they were used to inform the development of such an intervention in rural Nepal. Formative research was carried out in four parts. Part 1 involved familiarization with the study area and literature review, and parts 2, 3 and 4 involved community mapping, audit of health services, and qualitative and quantitative studies of perinatal care behaviors. Participatory approaches have been successful at reducing neonatal mortality and may be suitable in our context. Community mapping and profiling helped to describe the community context, and we found that community-based organizations often sought to involve the Female Community Health Volunteer in community mobilization. She was not routinely conducting monthly meetings and found them difficult to sustain without support and supervision. In health facilities, most primary care staff were in post, but doctors and staff nurses were absent from referral centers. Mortality estimates reflected under-reporting of deaths and hygiene and infection control strategies had low coverage. The majority of women give birth at home with their mother-in-law, friends and neighbors. Care during perinatal illness was usually sought from traditional healers. Cultural issues of shyness, fear and normalcy restricted women's behavior during pregnancy, birth and the postpartum period, and decisions about her health were usually made after communications with the family and community. The formative research indicated the type of intervention that could be successful. It should be community-based and should not be exclusively for pregnant women. It should address negotiations within families, and should tailor information to the needs of local groups and particular stakeholders such as mothers-in-law and traditional healers. The intervention should not only accept cultural constructs but also be a forum in which to discuss ideas of pollution, shame and seclusion. We used these guidelines to develop a participatory, community-based women's group intervention, facilitated through a community action cycle. The success of our intervention may be because of its acceptability at the community level and its sensitivity to the needs and beliefs of families and communities.

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