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Reducing Under 2 Mortality in Far West Nepal

In Far West Nepal, where we work, the number of under 5 deaths for every 1000 livebirths, compared to the national under-5 mortality rate of 69 per 1000 livebirths, is among the highest in the country. As a result, Possible has focused on monitoring and reducing deaths among children through the age of two years, noting the probability of a child dying is highest in the first month of the neonatal period and high in infancy (i.e. up to one year).

We do this by delivering integrated healthcare from hospital to home.

Our Community Health Worker (CHW) network helps us reach some of the most hard to access communities, including families that typically do not seek care facility-based care. CHWs regularly screen all under-two children for diarrhea and pneumonia, the leading causes for deaths among children under 5, in addition to other life-threatening conditions. They do this with the help of an Android-based mobile phone app, CommCare, specifically designed in collaboration with our partner Dimagi, to prompt and guide them through identifying symptoms using national and global standards. The app customizes the screening questions based on the child’s age and other risk factors, and facilitates the appropriate counseling and/or referral to a healthcare facility. It enables CHWs to track each patient records over time – for instance, if a child was referred to a healthcare facility for any reason during a previous visit.

CommCare doubles as a data collection tool integral to our electronic health record system. Since CHWs use it to record key information about the child’s health during every home visit, we are also able to aggregate these data over time and across the catchment area we serve to calculate population-level child mortality indicators such as under-two, infant, and neonatal mortality rates. This guides our programmatic decision-making and prioritization, allowing us to zoom in to the needs of our catchment population in a more localized way than national or other regional-level statistics are able to.

We have witnessed that pregnant women who have had the support of CHWs have experienced better planned pregnancies, safer births at healthcare facilities, and more timely referrals for acute cases.

That said, accurately estimating under-two mortality is no easy task. While a child’s death is an immensely delicate subject to broach with a bereaved mother, the high rate of migration in the region can pose challenges in ensuring follow-through for every single child at the population level. A miscount in the number of deaths can lead to inaccurate estimates because of small sample sizes, while improved detection could result in the appearance of a “spike” in mortality.

In 2015 and 2016, we estimated under-two mortality in the catchment communities surrounding Bayalpata Hospital using data collected by CHWs. Following the roll out of our CommCare app-based care-delivery in 2016, we started estimating under-two mortality using these ongoing, programmatic data instead of from one-time surveys. In 2017, we observed a much lower under-two mortality rate (18.5 per 1000 live births) compared to the preceding estimates (32.5 and 36.9 per 1000 live births), as well as lower infant and neonatal mortality rates. As we continue to iterate on generating these population-level statistics, our Community Healthcare team also works to better understand the individual circumstances behind each under-two child death so that we can prevent future deaths. And while we have reason to be optimistic, as long as even one child is at risk of death from a preventable or treatable condition, we still have work to do.

With the goal of eradicating preventable deaths among under-five children by 2030, the global Sustainable Development Goals envision reducing the under-5 mortality rate to 25 per 1000 live births in every nation .

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