Maternal and Newborn Health Care Practices Among Recently Delivered Women in Nepal

MATERNAL AND NEWBORN HEALTH CARE PRACTICES AMONG RECENTLY DELIVERED WOMEN IN NEPAL

March 2019 This publication was produced at the request of the United States Agency for International May 2011 Development. It was prepared independently by CAMRIS International.

DISCLAIMER The author’s views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States Government.

MATERNAL AND NEWBORN HEALTH CARE PRACTICES AMONG RECENTLY DELIVERED WOMEN IN NEPAL

March 2019 Contract Number AID-367-C-15-00001

Cover photograph: An enumerator administering the baseline survey questionnaire to a Recently Delivered Women in Kavre district. Credit: Suzanne Penfold Taylor

i STUDY TEAM MEMBERS

Suzanne Penfold Taylor, Team Leader, MEL Activity Manorama Adhikari, DCOP, MEL Activity Nira Joshi, National Consultant, New ERA Ganesh Sharma, Statistician/Data Analyst, MEL Activity

iii TABLE OF CONTENTS

Study Team Members ...... iii Table of Contents ...... iv List of Tables ...... xii Acronyms and Abbreviations ...... xvi KEY INDICATORS SUMMARY TABLE ...... xvii Executive Summary ...... xix Chapter 1: Background and Introduction ...... 1 1.1 Background ...... 1 1.2 Survey Objectives ...... 2 Chapter 2: Methods ...... 3 2.1 Study Population and Sample Size ...... 3 2.2 Survey Sample Selection ...... 3 2.2.1 Selection of Districts ...... 3 2.2.2 Selection of Clusters ...... 4 2.2.3 Selection of Households and Recently Delivered Women ...... 4 2.3 Survey Tools ...... 5 2.4 Implementation of Survey ...... 6 2.4.3 Field Test of the Survey Instruments ...... 7 2.5 Refresher Training and Data Collection ...... 7 2.6 Quality Control...... 9 2.7 Data Entry, Cleaning, and Analysis ...... 9 2.8 Research Ethics ...... 10 Chapter 3: Sample Characteristics ...... 11 3.1 Socio-Demographic Characteristics of the Respondents ...... 11 3.2 Housing Characteristics ...... 12 3.3 Household Possessions ...... 13 3.4 Sources of Drinking Water ...... 13 3.5 Types of Toilet Facility ...... 14 3.6 Household Wealth Quintiles ...... 14 Chapter 4: RDW Knowledge about FCHV and Health Mother's Group ...... 15 4.1 Recently Delviered Women’s Knowledge about Female Community Health Volunteers (FCHVs) ...... 15 4.2 Health Mother's Groups ...... 16 Chapter 5: Antenatal Care ...... 18 5.1 Antenatal Care Service Utilization ...... 18 5.2 Types of Services and Counseling Received During Antenatal Care (ANC) 21 5.3 Tetanus Toxoid Immunization ...... 23 5.4 Intake of Iron Folic Acid Tables and Deworming Tablets ...... 24 5.5 Knowledge about Danger Signs and Service Seeking Behavior During Pregnancy 25 5.6 Danger Sign Encountered During Pregnancy and Management of the Problems 26 5.7 Birth Preparedness ...... 27 5.8 CHX Knowledge and Receipt ...... 28 Chapter 6: Delivery Care and Coverage of Misoprostol or Matri Surakshya Chakki (MSC) ... 30

iv 6.1 Assistance During Delivery ...... 30 6.2 Place of Delivery ...... 32 6.3 Access to Services during Delivery ...... 33 6.4 Experienced Danger Signs During and After Delivery of the Last Child . 35 6.5 Awareness of Misoprostol “Matri Suraksha Chakki” ...... 36 Chapter 7: Postpartum Care ...... 39 7.1 Female Community Health Volunter Home Visits During the Postpartum Period 39 7.2 Postpartum Checkups ...... 40 7.3 Intake of Iron Folic Acid Tablets and Vitamin A Capsule in the Postpartum Period ...... 43 7.4 Awareness of Danger Signs During the Postpartum Period (PP) ...... 44 Chapter 8: Immediate Newborn Care in Home Deliveries, and Application of Substances to the Cord ...... 45 8.1 Immediate Newborn Care Among Home Deliveries ...... 45 8.2 Umbilical Cord Cutting Practices ...... 46 8.3 Application of Substances to the Umbilical Cord (all live births) ...... 47 8.4 Problems with the Umbilical Cord (All Live Births) ...... 51 Chapter 9: Newborn Care During the First Month ...... 52 9.1 Knowledge of Issues in Newborn Care ...... 52 9.2 Access to Neonatal Checkup Services...... 53 9.3 Health Issues Encountered by Neonates and Treatment-Seeking Behaviors After Encountering Health Problems ...... 54 9.4 Child’s Weight and Size at Birth ...... 55 9.5 Care for Newborn Perceived to be Smaller Than Average ...... 56 Chapter 10: Infant and Young Child Feeding Practices ...... 57 10.1 Initiation of Breastfeeding ...... 57 10.2 Exclusive Breastfeeding Practices ...... 59 10.3 Introduction of Complementary Foods ...... 60 10.4 Minimum Dietary Diversity ...... 61 10.5 Types of Complementary Foods ...... 62 Chapter 11: Postpartum Family Planning ...... 63 11.1 Family Planning Practices ...... 63 Chapter 12: Conclusions ...... 64 REFERENCES ...... 65 Appendix 1: List of Selected Clusters ...... 81 Appwndix 2: Evaluation Scope of Work...... 86 Appendix 3: Data Collection Support Letter ...... 91 Appendix 4: Nepal Health Research Center (NHRC) Ethical Clearance ...... 92 Appendix 5: Personnel Involved in the Survey ...... 93 (New Era) ...... 93 Appendix 6: Questionnaire ...... 94

v LIST OF TABLES

Table 2.2.3: Number of Districts, Clusters, and Respondents in Each Province ...... 5 Table 3.1: Percent Distribution of RDW by Socio-demographic Characteristics ...... 11 Table 3.2: Percent Distribution of Housing Characteristics of RDW ...... 12 Table 3.3: Percent Distribution of Household Possessions of RDW ...... 13 Table 3.4: Percent Fistribution of Source of Drinking Water Reported by RDW ...... 13 Table 3.5: Percent Distribution of Types of Toilet Facility of RDW ...... 14 Table 3.6: Percent Distribution of RDW by Wealth Quintile...... 14 Table 4.1: Percent Distribution of RDW, By Their Background Characteristics, Who Know a FCHV and Who Met a FCHV During Their Last Pregnancy ...... 15 Table 4.2: Percent Distribution of RDW Who Know of a Health Mother's Group in Her Area and Attending the meeting During Their Last Pregnancy ...... 16 Table 4.3: Percent Distribution of Topics Discussed in HMG Meetings Reported by RDW 17 Table 5.1: Percent Distribution of the Number of ANC Visits and Month of Pregnancy When Received the First ANC Through Health Workers Reported by RDW ...... 18 Table 5.2: Percent Distribution of Antenatal Care Provider and Receiving At Least One Antenatal Care From a Skilled Provider According to Background Characteristics of RDW 19 Table 5.3: Percent Distribution of RDW Who Attended ANC During the Recommended Months of Pregnancy According to Background Characteristics ...... 20 Table 5.4: Percent Distribution of Place of Last ANC Visit Reported by RDW ...... 21 Table 5.5: Percent Distribution of RDW Receiving Specific Antenatal Services Among Those Who Received ANC Services According to Background Characteristics ...... 21 Table 5.6: Percent Distribution of the Types of Counselling Received From Health Workers During ANC Visit Reported by RDW ...... 22 Table 5.7: Percent Distribution of RDW Who Received At Least One TT Injection, and Who Received Two or More TT Injections During Their Pregnancy By Background Characteristics ...... 23 Table 5.8: Percent Distribution of RDW Who Took Iron Folic Acid Tablets and Intestinal Parasite Drugs During Their Pregnancy By Background Characteristics ...... 24 Table 5.9: Percent Distribution of Awareness of Danger Signs During Pregnancy and Places to Go When Those Signs Persist Reported by RDW ...... 25 Table 5.10: Percent Distribution of RDW Who Encountered a Danger Sign During Pregnancy and Actions Taken for the Problems Encountered ...... 26 Table 5.11: Percent Distribution of RDW Reporting Different Types of Birth Preparedness# ...... 27 Table 5.12: Percent Distribution of RDW Reporting Any Birth Preparedness According to Background Characteristics ...... 27 Table 5.13: Percent Distribution of RDW Who Received CHX During Pregnancy According to Background Characteristics ...... 28 Table 5.14: Percent Distribution of the Source of CHX Receipt During Pregnancy ...... 28 Table 5.15: Percent Distribution of Source of CHX Receipt During Pregnancy ...... 29 Table 5.16: Reasons Given for Not Obtaining CHX During Last Pregnancy by Recently Delivered Women ...... 29 Table 5.17: Percent Distribution of Cited Purpose of Using and How to Use CHX Reported by RDW ...... 29 Table 6.1: Percent Distribution of Persons Providing Assistance During Delivery and Persons Present Outside the Room During Delivery Reported by RDW ...... 30

xii Table 6.2: Percent Distribution of RDW Who Received Assistance From SBA1 During Delivery By Background Characteristics ...... 31 Table 6.3: Percent Distribution of RDW by Place of Delivery According to Background Characteristics ...... 32 Table 6.4: Percent Distribution of RDW Who Received an Injection of Oxytocin Immediately After Delivery and Who Had a Caesarian Section for Delivery Among Those Delivered in a Health Facility According to Background Characteristics ...... 33 Table 6.5: Percent Distribution of RDW Who Paid Cash to the Health Facility Among Those Delivered in a Health Facility According to Background Characteristics ...... 34 Table 6.6: Percent Distribution of RDW Who Encountered a Danger Sign During Delivery and Actions Taken for the Problems Encountered ...... 35 Table 6.7: Percent Distribution of RDW Who Were Referred After Encountering a Danger Sign During Delivery and the Place They Went After Receiving the Referral; and the Reasons for Not Going to the Referred Place Among Those Who Didn't G ...... 35 Table 6.8: Percent Distribution of RDW’s Knowledge on Purpose and Timing of Taking MSC, and the Conditions to Avoid Matri Suraksha Chakki (MSC) ...... 36 Table 6.9: Percent Distribution of Recently Delivered Women (RDW) Who Had Received Matri Surakshya Chakki (MSC), and Among Those Who Had Received It, the Person Who Gave Them the MSC, Number of MSC Given and the Mean Month of Pregnancy When MSC Was Received ...... 37 Table 6.10: Percent Distribution of Reasons Given by RDW of Not Receiving Matri Surakshya Chakki (MSC ) ...... 37 Table 6.11: Percent Distribution of RDW by Their Knowledge on Precautions to be Taken With MSC as Communicated by the FCHV or Health Worker ...... 37 Table 6.12: Percent Distribution of Side Effects of Tablets as Reported by RDW# ...... 38 Table 6.13: Percent Distribution of the Number and Timing of Matri Surakshya Chakki (MSC) Intake as Reported by RDW Among Home Deliveries ...... 38 Table 7.1: Percent Distribution of Timing of First and Further Home Visits by FCHV Within Six Weeks Following the Birth of Their Last Child as Reported by RDW ...... 39 Table 7.2: Percent Distribution of the Number of Postpartum Checkups Within Six Weeks of Delivery by Health Workers or FCHV as Reported by RDW ...... 40 Table 7.3: Percent Distribution of Postpartum Checkups Within Six Weeks of Delivery by Health Workers as Reported by RDW (by background characteristics) ...... 40 Table 7.4: Percent Distribution of the Timing of the First Postpartum Check-up Within Six Weeks of Delivery and the Type of Health Worker Who Provided the Check-up by the Place of Delivery as Reported by RDW ...... 41 Table 7.5: Percent Distribution of the Timing of the Second Postpartum Check-up and the Type of Health Worker Who Provided the Check-up Reported by RDW ...... 41 Table 7.6: Percent Distribution of Places Visited for Postpartum Checkups Within Six Weeks of Delivery as Reported by RDW ...... 42 Table 7.7: Percent Distribution of the Types of Postpartum Checkup Service Components Received as Reported by RDW ...... 42 Table 7.8: Percent Distribution of RDW According to Background Characteristics Who Took Iron Folic Acid Tablets and Vitamin A Capsule During Their Post-Partum Period ...... 43 Table 7.9: Percent Distribution of Reported Postpartum Danger Signs and Where to Seek Care by RDW ...... 44 Table 7.10: Percent Distribution of RDW by Postpartum Danger Signs Informed by Health Workers ...... 44 Table 8.1: Percent Distribution of Immediate Newborn Care Practices Among Home Delivery as Reported by RDW ...... 45

xiii Table 8.2: Percent Distribution of the Type of Instrument Used to Cut and Tie the Umbilical Cord Among Home Deliveries as Reported by RDW ...... 46 Table 8.3: Percent Distribution of the Type of Surface Used While Cutting the Cord Among Those RDW Who Had Not Used CHDK in Home Deliveries ...... 46 Table 8.4: Percent Distribution of the Substance Used on the Cord Stump of the Newborn as Reported by RDW ...... 47 Table 8.5: Percent Distribution of RDW by CHX Application on Umbilical Cord of the Newborn by Background Characteristics of RDW ...... 47 Table 8.6: Percent Distribution of Reasons Cited for Not Applying CHX Despite Receiving It During Pregnancy as Reported by RDW ...... 48 Table 8.7: Percent Distribution of Person Applying CHX on the Umbilical Cord Stump of the Newborn as Reported by RDW ...... 48 Table 8.8: Percent Distribution of the Timing of Application of the CHX After the Cutting of the Umbilical Cord as Reported by RDW ...... 48 Table 8.9: Percent Distribution of Different Aspects of CHX Application Among Home Deliveries as Reported by RDW ...... 49 Table 8.10: Percent Distribution of RDW by Background Characteristics Among Home Deliveries Who Met Compliance of CHX ...... 50 Table 8.11: Percent Distribution of the Types of Problem Encountered in the Cord Stump, Action Taken Against the Problem, and the Timing of the Cord Stump Fall as Reported by RDW ...... 51 Table 9.1: Percent Distribution of RDW by Their Knowledge About Newborn Issues as Reported by RDW ...... 52 Table 9.2: Percent Distribution of Health Services Received by Newborn as Reported by RDW ...... 53 Table 9.3: Percent Distribution of Newborn According to Number of Times Health Services Received by Health Worker or FCHV as Reported by RDW...... 53 Table 9.4: Percent Distribution of Types of Health Problems Faced by Newborns Within Eight Weeks of Birth as Reported by RDW ...... 54 Table 9.5: Percent Distribution of Health Seeking Behavior Pertaining to Neonatal Health Issues as Reported by RDW ...... 54 Table 9.6: Percent Distribution of Aspects of Weighing the Newborns as Reported by RDW ...... 55 Table 9.7: Percent Distribution of Care Provided to Newborns Who Were Perceived as Small as Reported by RDW ...... 56 Table 9.8: Percent Distribution of Types of Advice Given by HW or FCHV Because the Child Was Small As Reported by RDW ...... 56 Table 9.9: Percent Distribution of Types of Care Provided by RDW Because the Child Was Small 56 Table 10.1: Percent Distribution of Breastfeeding Practices Among RDW ...... 57 Table 10.2: Percent Distribution of RDW by Background Characteristics Who Breastfed Their Last Child Within One Hour of Birth...... 58 Table 10.3: Percent Distribution of RDW Who Exclusively Breastfed Their Child Under Six Months of Age by Background Characteristics ...... 59 Table 10.4: Percent Distribution of RDW by BackGround Characteristics Who Had Introduced the Complementary Food to Their Child Age 6-8 Months ...... 60 Table 10.5: Percent Distribution by Background Characteristics of RDW Who Had Been Given Food From Four or More Groups for Their Children Ages 6-11 Months the Day Prior to the Survey ...... 61

xiv Table 10.6: Proportion of RDW Reporting Food and Liquid Consumed by Children in the Preceding Day of the Survey ...... 62 Table 11.1: Percent Distribution of Family Planning Practice After Birth of the Last Child Reported by RDW ...... 63

xv ACRONYMS AND ABBREVIATIONS

ANC Antenatal Care BCG Bacillus Calmette-Guérin BPP Birth Preparedness Package CB IMNCI Community-Based Integrated Management of Neonatal and Childhood Illness CNCP Chlorhexidine Navi Care Program CHD Child Health Division CHDK Clean Home Delivery Kit CHX Chlorhexidine DHO District Health Office DoHS Department of Health Service DTP3 Diphtheria-Tetanus-Pertussis EPI Expanded Program on Immunization FCHV Female Community Health Volunteer FP Family Planning HMG Health Mothers’ Groups HP Health Post HW Health Worker IMR Infant Mortality Rate IQR Inter-Quartile Ranges IYCF Infant and Young Child Feeding LDO Local Development Office MEL Monitoring, Evaluation and Learning MMR Maternal Mortality Ratio MNH Maternal and Neonatal Health MNTE Maternal and Neonatal Tetanus Elimination MOHP Ministry of Health and Population MSC Matri Surakshya Chakki NDHS Nepal Demographic and Health Survey NMR Neonatal Mortality Rate ORC Outreach Clinics PHCC Primary Health Care Centers PNC Postnatal Checkups PPH Postpartum Hemorrhage PPS Proportional to Population Size RDW Recently Delivered Women SBA Skilled Birth Attendants SHP Sub-Health Posts SLC School Leaving Certificate TT Tetanus Toxoid USAID United States Agency for International Development VDC Village Development Committee

xvi KEY INDICATORS SUMMARY TABLE

(N=3661) Exposure to FCHV and Health Mother's Group % n Percentage of RDW who knew FCHV in their area 3200 87 Percentage of RDW who met a FCHV during their last pregnancy1 2024 63 Percentage of RDW who knew about a health mother's group (HMG) 1224 33 Percentage of RDW who attended a HMG meeting during their last pregnancy2 453 37 (N=3538) Antenatal Care % n Percentage of RDW who received ANC from a skilled provider3 3384 96 Percentage of RDW who attended ANC during all specified months (4th, 6th, 8th, and 9th month)3 1556 44 Percentage of RDW who took iron folic acid tablets during pregnancy4 3496 96 Percentage of RDW who took recommended 180 or more iron folic acid tablets during pregnancy5 1910 55 Percentage of RDW who took a de-worming tablet during pregnancy3 3183 90 Percentage of RDW who knew at least three out of six danger signs during pregnancy4,6 3288 90 Percentage of RDW who encountered at least one danger sign during pregnancy7 1425 39 Percentage of RDW who had taken at least three out of six birth preparedness actions4,8 2270 62 Percentage of RDW who had received CHX during pregnancy4 715 20 (N=3661) Delivery Care and Misoprostol % n Percentage of RDW whose delivery was attended by a SBA 2666 73 Percentage of RDW who delivered in a health facility 2696 74 Percentage of RDW who encountered a danger sign during delivery9 1432 39 Percentage of RDW who have heard of Misoprostol 130 4 Percentage of RDW who received Misoprostol tablets10 57 44 Percentage of RDW who took Misoprostol among those who had delivered in home and had 10 77 received Misoprostol during pregnancy11 (N=3661) Postpartum Care % n Percentage of RDW who had a home visit by a FCHV after the birth of their child 1261 34 Percentage of RDW who had a first home visit by a FCHV on the same day of delivery12 394 31 Percentage of RDW who had a second home visit by a FCHV on the 3rd day after the birth of their 79 12 child13 Percentage of RDW who had a third home visit by FCHV on the 7th day after the birth of their 37 11 child14 Percentage of RDW who had postpartum checkups within 7 days of delivery by health workers 2639 100 among institutional delivery15 Percentage of RDW who had postpartum checkups within 7 days of delivery by health workers 248 82 among home delivery16 Percentage of RDW who took iron folic acid tablets during Postpartum 2482 68 Percentage of RDW who took the recommended dose of at least 42 iron folic acid tablets during 1153 46 Postpartum17 Percentage of RDW who took a vitamin A capsule during Postpartum 1953 53 Percentage of RDW who know at least three out of five danger signs during Postpartum18 3328 91 (N=3661) Immediate Newborn Care and CHX Usage % n Percentage of RDW who reported that the persons who helped them during delivery washed their 587 61 hands among those who had a live birth at home19 Percentage of RDW who had a live birth at home and reported CHDK or a new blade was used to 774 81 cut the umbilical cord Percentage of RDW reporting CHX was applied onto the cord stump of the newborn7 2159 59 Percentage of RDW who reported compliance with the CHX application process20, 21 200 62 (N=3661) Newborn Care During the First Month After Birth % n Percentage of RDW reporting their newborns were checked by health workers or a FCHV within 2965 88 four weeks of birth22 Percentage of RDW reporting that the newborns encountered a danger sign during the first eight 1935 61 weeks23

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(N=3644) Infant and Young Child Feeding Practices % n Percentage of RDW whose child was breastfed 3628 99 Percentage of RDW whose child was breastfed within one hour of birth24 2212 61 Percentage of RDW whose child was exclusively breastfed25 889 64 Percentage of RDW whose child was timely introduced to complementary foods26 662 88 Percentage of RDW whose child received the minimum dietary diversity27 511 32 (N=3661) Family Planning after Child Birth % n Percentage of RDWs who reported receiving counseling on family planning after their child's birth 2106 58 Percentage of RDW who have used family planning after their child's birth 1452 40 1Total includes those RDW who knew a FCHV (N=3,200) 2Total includes those RDW who knew a HMG (N=1,224) 3Total includes those RDW who received at least one ANC (N=3,538) 4Total includes all RDW (N=3661) 5Total includes those RDW who had consumed iron folic tablets in pregnancy (N=3496) 6The six danger signs during pregnancy include blurred vision, severe lower abdominal pain, severe headache, convulsion, swelling of hands and face, and vaginal bleeding. 7Total includes those RDW who had a live birth (N=3647) 8The six types of birth preparedness include saved money, arranged for transportation, identified a health facility, found a blood donor, identified health workers, and arranged cloths. 9Danger sign during delivery includes: labor longer than 8 hours, appearance of baby’s hand/leg/placenta first, excessive bleeding before or after delivery, and convulsion. 10Total includes those RDW who have heard of Misoprostol (N=130) 11Total includes those RDW who had a home delivery (includes all places except health institutions) and received Misoprostol during pregnancy (N=13) 12Total includes those RDW who had at least one home visit by a FCHV (N=1259) 13Total includes those RDW who had at least two home visits by a FCHV (N=639) 14Total includes those RDW who had at least three home visits by a FCHV (N=326) 15Total includes those RDW who had an institutional deliverey and received a PP checkup (N=2641) 16Total includes those RDW who had a PP checkup among home delivery (N=303) 17Total includes those RDW who had consumed iron folic tablets in postpartum (N=2482) 18The five postpartum danger signs include fever, pain in the lower abdomen or smelling vaginal discharge, excessive bleeding, a severe headache, and convulsion. 19Total includes those RDW who had a live birth and delivered in home (N=957) 20Total includes those RDW who had a home delivery and have reported applying CHX (N=321) 21Compliance means RDW reported a person washing their hands before applying CHX, CHX applied within two hours of delivery, applied CHX to both cord and stump, and left untouched for some time. 22Total includes those RDW who had a live birth and the newborn was over one month of age at the time of the interview (N=3387) 23Total includes those RDW who had a live birth and the newborn was over two months of age at the time of the interview (N=3192) 24Total includes those RDW whose child was ever breastfed (N=3628) 25Total includes those RDW whose child was under six months of age at the time of the interview (N=1387) 26Total includes those RDW whose child was six to eight months of age at the time of the interview (N=757) 27Total includes those RDW whose child was six to 11 months at the time of the interview (N=1610)

xviii EXECUTIVE SUMMARY

Background

The Nepal Demographic and Health Survey (NDHS) 2016 found that 54 percent of under age 5 deaths and 66 percent of infant mortality took place during the first month of birth, indicating that unless neonatal deaths are significantly reduced, decline in infant and child mortality rates cannot be achieved. For a holistic improvement in maternal and neonatal health (MNH), the country has implemented several national and sub-national programs. These include the expanded program on immunization (EPI), antenatal care (ANC), birth preparedness package (BPP), postnatal checkups (PNC), promotion of skilled birth attendants (SBA), immediate newborn care, family planning (FP) services, community-based integrated management of neonatal and childhood illness (CB-IMNCI), and infant and young child feeding (IYCF). The Department of Health Service also recommends applying Chlorhexidine (CHX) to the freshly cut umbilical cord stump as one of the essential newborn care practices.

The purpose of this study was to assess the maternal and newborn health care practices among recently delivered women (RDW) at the community level in CHX implemented districts. RDW was defined as women between 15- and 49-years-old living in the selected districts who had given birth to a live baby or had a still birth in the 15 months preceding the survey.

Methodology

The sampling frame included all 58 districts of Nepal where the CHX program was implemented at the facility and community level for at least a year at the time of the survey. The survey team selected the study districts using the sampling proportional to population size (PPS), stratified by province and ecological region, making a total of 21 districts selected at random allowing each province and ecological region representation. From each district, the team selected eight village development committees (VDCs), and from each VDC, two clusters (wards) at random and proportional to population size, making a total of 336 clusters. The survey team also conducted a census of households in the clusters, and from each cluster, randomly selected 11 households with RDW but confirmed that the RDW had had a pregnancy lasting of at least seven months in the 15 months preceding the survey since Baishakh 2073 (April 2016). The survey team received ethical approval from Nepal Helath Research Council (NHRC) prior to the field work.

Results

Background Characteristics The survey team visited 55,247 households and identified 72,007 women of reproductive age. Of these, 3,664 women had a pregnancy that ended in a live birth or stillbirth since Baishak 2073 (April 2017), and 3,661 agreed to participate.

Most RDW (42 percent) were between 20 and 24 years old with the median age being 23 years old. Most respondents had attended secondary (38 percent) and school leaving certificate (SLC) and above education (31 percent) while 19 percent participants had no education. The most common ethnic groups in the study were Brahmin/Chhetri (37 percent) and Janajaties (34 percent).

Ninety-six percent of households had electricity and a similar proportion had a mobile phone. Almost half of the households owned a television (49 percent) while around two-thirds (35 percent)

xix had a radio. Ninety-two percent of households used an improved source of drinking water while around 9 percent used a non-improved source. Overall, 7 percent households do not have toilet facilities.

RDW Knowledge about a Female Community Health Volunteer (FCHV) and Health Mother's Group (HMG)

Eighty-seven percent of RDW knew there is an FCHV in their area, and among those who knew, 63 percent had met with an FCHV at least once during their last pregnancy. A lower proportion of RDW in Terai and Province 2 knew their FCHV. A higher percentage of RDW in the hill area reported meeting their FCHV. RDW's knowledge of FCHVs was highest in Province 6 and 7 (96 percent each). The proportion of RDW meeting with their FCHV was lowest in Province 1 (45 percent) and highest in Province 6 (73 percent).

Thirty-three percent of RDW reported that there was a health mother’s group (HMG) in their area, with 53 percent reporting in Province 6 and 52 percent reporting in Province 7. Only 27 percent in Terai and 10 percent in Province 1 reported knowing a HMG. Among those RDW who knew HMG, 37 percent had attended a HMG meeting during their last pregnancy ranging from 17 percent in province 4 to 55 percent in province 7 and from 26 percent in Terai to 45 percent in Hill.

Antenatal Care ANC services-seeking behavior was almost universal in the study districts, with only 3 percent not receiving any ANC. While 20 percent of them attended ANC less than four times, four in ten (42 percent) attended ANC four times, and 35 percent attended more than four times. Fourty-four percent of RDW who went for ANC Checkups had received ANC checkups during all specified months (4, 6, 8 and 9 months) ranging from 27 percent in Province 2 to 66 percent in Province 7. Among the RDW who received ANC, the majority (96 percent) had received it from a skilled provider. Among women who received ANC, almost all (99 percent) reported that they had their abdomen examined, 96 percent had their weight measured and the same proportion had their blood pressure measured, 85 percent had a urine sample taken, and 77 percent had blood samples taken.

Ninety-eight percent of RDW had received at least one tetanus toxoid (TT) shot and 72 percent had received two TT shots during their last pregnancy. The proportion of women receiving at least one TT shots was highest in the Terai region. The proportion of women getting two or more TT shots ranged from 61 percent in Province 6 to 84 percent in Province 3.

Ninety-six percent of RDW took iron-folic acid tablets in their last pregnancy and among those who took the tablets, 55 percent had taken the recommended dose of at least 180 tablets. The proportion of RDW taking iron folic acid tablets ranged from 89 percent in Province 2 to 98 percent in Province 7. A greater proportion of women who were younger, literate, had SLC and above level of education, and wealthier reported taking iron folate in their last pregnancy. Ninety percent of RDW had taken de-worming tablets in their last pregnancy. Intake of deworming tablets ranged from 86 percent in the Terai region to 93 percent in Hill regions and from 76 percent in Province 2 to 96 percent in Province 7.

Seventy-one percent of RDW regarded “severe lower abdominal pain” as one of the danger signs that may appear during pregnancy which would require immediate medical attention, 67 percent reported “vaginal bleeding,” 31 percent “a severe headache,” 28 percent “no fetal movement,” and 22 percent “swelling of hand and faces of pregnant women” as danger signs that may occur during pregnancy. Among the RDW who had live birth, 37 percent had encountered at least three danger signs during pregnancy, 2 percent had more than three danger signs encountered, and 61 percent

xx had not had any problem encountered during pregnancy. Seventeen percent of the RDW who encountered problems in their last pregnancy took no action to resolve them.

Eighty-nine percent of RDW had made at least one birth preparedness plan. Among all RDW, 76 percent had saved money, 73 percent arranged cloths, 22 percent had arranged transport, 14 percent had identified a health facility for delivery, 4 percent identified a blood donor, and 2 percent identified a health worker for delivery. Sixty-two percent of RDW had done at least three types of preparation out of six types while less than one percent had done all six types of birth preparedness. The RDW reporting any birth preparedness ranged from 87 percent each in Mountain and Hill to 92 percent in Terai and from 82 percent in Province 7 to 92 percent each in Province 1 and 6.

Twenty percent of RDW received CHX during pregnancy ranging from 16-17 percent in Mountain and Terai to 24 percent in Hill, and from 8 percent in Province 4 to 34 percent in Province 5. Among those who had received CHX, the majority (62 percent) had received it from FCHV and in the eighth and ninth month of pregnancy (48 percent and 41 percent respecitvely).

Delivery Care and Coverage of Misoprostol Seventy-three percent of women delivered with a skilled birth attendant (SBA). SBAs assisted approximately 66 percent of the deliveries in the Mountain, 72 percent in the Hill, and 77 percent in the Terai regions. Seventy-four percent of RDW delivered their last child at a health facility, ranging from 68 percent in the Mountain zone to 77 percent in the Terai zone, and from 57 percent in Province 2 to 86 percent in Province 7. Among those RDW who delivered in a health facility, 80 percent had received an injection of oxytocin, which ranged from 73 percent in Hill to 85 percent in Terai, and from 71 percent in Province 6 to 96 percent in Province 2. Overall, 15 percent of deliveries were by caesarian section. The proportions of caesarian deliveries ranged from 10 percent in Hill to 19 percent in Terai, and from 6 percent each in Province 6 and 7 to 26 percent in Province 1.

Among all RDW, almost four in ten (39 percent) had encountered at least one danger sign during delivery and among them majority (86 percent) had labor longer than 8 hours. Among those who encountered danger sign and were referred, 16 percent didn’t go to the referral facility for treatment because the facility being too far (50 percent).

Among all RDW, only around 4 percent had heard of misoprostol or Matri Suraksha Chakki (MSC) and among those who had heard of MSC, 44 percent had received it. Of the total RDW who had received the tablets and had home deliveries, 23 percent had not consumed any tablets while the remaining 77 percent had consumed all three tablets.

Postpartum Care

Within the first six weeks of delivery, 34 percent of RDW were visited at home by FCHV. Among those who were visited by FCHV, 23 percent had received one visit, 51% had recived two visits and 26% had received three visits. Among the RDW who were visited by FCHV for postpartum care, 31 percent were visited on the day of delivery; among those who were visited the second time, 12 percent were visited on the third day as recommended; and among those who were visited the third time, 11 percent were visited on the 7th day of the delivery.

Among all institutional deliveries, 99 percent of RDW had at least one postpartum checkup and among them, almost all were done on the same day of delivery. Among home deliveries, only 31 percent had at least one postpartum checkup and among them 67 percent had the checkup on the same day of delivery with mean number of first check up being 4.45 days for those having home deliveries.

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Thirty-two percent of RDW had not taken any iron-folic-acid tablets during the postpartum period and among those who had taken, 47 percent had taken the recommended dose of at least 42 tablets. The proportion of RDW reported taking postpartum iron folic acid tablets ranged from 63 percent in Terai to 71 percent in Mountain and Hill, and from 37 percent in Province 2 to 77 percent in Province 5.

Fifty-three percent of RDW reported consuming vitamin A within six weeks of delivery, with significantly higher in Hill (59 percent) and in Province 7 (72 percent).

Immediate Newborn Care and Coverage and Compliance of Chlorhexidine Most (61 percent) RDW who gave birth at home said that the person helping them with the birth washed their hands before handling the baby. Just under half (46 percent) of RDW delivered in home reported that the baby was dried before the placenta was delivered, the vast majority (94 percent) with a clean and dry cloth. For the majority of RDW who gave birth at home, their baby was wrapped after the placenta was delivered (61 percent), and again the clear majority used a clean and dry cloth (99 percent). Most commonly, RDW reported that the baby was placed on the floor (48 percent) before the placenta was delivered and that the cord was cut within five minutes of birth (38 percent).

Two-thirds of RDW who gave birth at home reported that their baby’s cord was cut with a new blade and 14 percent reported using a clean home delivery kit (CHDK). For tying the umbilical cord, the majority of RDW had used a new thread (85 percent). Those RDW who had not used CHDK were further asked about the surface used to place the cord while cutting. Around a third (31 percent) of RDW reported using wooden surfaces and another third (32 percent) reported not using any type of surface for cutting the cord.

Among all births, over half (59 percent) reported CHX was applied and another 11 percent reported oil was applied. Almost three in ten (27 percent) of RDW reported that nothing was applied to the newborn's cord. The proportion of RDW reported CHX application varied by ecological zone and province, ranging from 53 percent of RDW in the Mountain zone to 66 percent of women in the Hill zone, and from 39 percent of women in Province 2 to 74 percent of women in Province 7. CHX application also varied by age, literacy level, education level, ethnicity, and the wealth of the women. CHX application rates ranged from 48 percent of women aged 35-49 years to 61 percent of women age 25-29 years. Application rates were higher among women who were literate, more educated, and wealthier. Application rates ranged from 41 percent among other Terai castes and religious minorities to 71 percent of Brahmin/Chhetri.

The person most commonly reported to apply CHX was the health worker (87 percent). Most women reported that CHX was applied within 2 hours of cutting the cord. The majority (62 percent) of RDW who reported that CHX was applied to the cord reported all four aspects of correct application (applier washed hands before application, whole tube applied, applied to cord and surrounding area, and cord left untouched for some time) to have been carried out. The level of compliance only varied significantly by ethnic group, ranging from 53 percent of Janajaties to 73 percent of Brahmin/Chhetri.

Fifteen percent RDW reported that their child had a problem with their umbilical cord, and among them, most commonly an infection (74 percent). Most RDW (42 percent) reported taking their child to a health facility for the problem.

xxii Newborn Care During the First Month Eighty-eight percent of RDW reported that a health worker (HW) or FCHV had checked their child's health within the first month after birth. While one third of neonates had received the checkup from health workers once during the first month after birth, the same number of neonates had received the checkups twice in the first month. The majority (90 percent) of neonates among those who received checkups from HWs received their first Checkup on the day of delivery while 65 percent among those who were checked by FCHV received the checkup on the day of delivery.

Almost all (97 percent) RDW reported that the Bacillus Calmette-Guérin (BCG) vaccine was given to their newborns.

In total, 92 percent born alive were weighed. Among those who were measured, 84 percent were weighed the same day they were born, while 14 percent were weighed for the first time three days after birth. Among those who were measured at birth (on the day of birth), 9 percent were reported to be less than 2.5 kg. As per RDW’s perceptions on the size of their newborns, 11 percent reported smaller than average or very small. Among newborns who were small, 35 percent were visited by health workers or FCHVs more than the usual times, and 35 percent were referred to a health facility. Among those who were referred, 57 percent were taken to the health facility as advised. Eighty-six percent reported providing extra care to the child because of their small size.

Infant and Young Child Feeding Practices Almost all the children were breastfed at some time. Sixty-one percent of children were initiated with breastfeeding within one hour of birth. The proportion of RDW initiating breastfeeding within one hour of delivery ranged from 54 percent in Terai to 70 percent in Hill and from 43 percent in Province 2 to 77 in Province 7. The practice of pre-lacteal feeding was reported by a considerable proportion of RDW (15 percent).

Sixty-four percent of children were exclusively breastfed. The exclusive breastfeeding practice varied from 52 percent in Terai to 73 percent in Hill, and from 53 percent in Province 3 to 79 percent in Province 6.

Eighty-eight percent of the children aged six to eight months were given solid/semi-solid food the preceding day. The proportion of children receiving the complementary food varied from 81 percent in Terai to 91 percent in Mountain and Hill, and from 72 percent in Province 2 to 94 percent in Province 5 and 6.

Among children aged 6-11 months, only 32 percent had received the recommended minimum dietary diversity. The percentage of children who had received the minimum dietary diversity ranged from 27 percent in Terai to 37 percent in Hill, and from 15 percent in Province 2 to 48 percent in Province 5.

Postpartum Family Planning Fifty-eight percent of RDW reported that they get advice from HWs about using family planning (FP) methods after the delivery of the child. Among all, 40 percent of RDW had used any FP method. Among the RDW who used a FP method, the common method used was "Depo-Provera" followed by "condom" and "withdrawal." The majority of the RDW among those who used FP methods reported using it within 3-6 months of the birth of the child at 3.8 mean months.

xxiii Conclusions

The overall findings of the survey show that the coverage of maternal and newborn health programs is high in the study areas. However, there are high variations in service utilization by geographic, demographic, and socio-cultural factors. The MNH indicators such as ANC practices, taking TT vaccine and consumption of iron folic acid tablets during pregnancy was high. The study also shows encouraging results of three-fourth deliveries as institutional delivery. Further, it shows that CHX componenet in the newborn care package has been successful in achieving a high coverage and compliance of application among the newborns. The study results demonstrated good knowledge among RDW regarding danger signs during antenatal and postnatal period and good knowledge and practice regarding newborn care.

Although the study shows a good status for many of the MNH indicators, there are some areas where the program should put more focus on, such as postpartum care as recommended and coverage of MSC tablets. Additionally, the study also notes an issue of applying several types of substances other than CHX in the cord stump of the child.

xxiv CHAPTER 1: BACKGROUND AND INTRODUCTION

1.1 Background

Health care services during pregnancy, childbirth, and the Postpartum period are important for the survival and well-being of both mothers and neonates. Over the last twenty years, Nepal has achieved significant reductions in childhood mortality and made progress in maternal health. Between 1996 and 2016, the neonatal mortality rate (NMR) fell from 50 to 21 deaths per 1,000 live births, the infant mortality rate (IMR) declined from 78 to 32 deaths per 1,000 live births, and the under-5 mortality rate fell from 118 to 39 deaths per 1,000 live births [Ministry of Health and Population (MOHP) Nepal, New ERA, ICF International, 2017]. The Nepal Demographic and Health Survey (NDHS) 2016 shows that the maternal mortality ratio (MMR) is 239 deaths per 100,000 live births for the period 2009-2016 (MOHP Nepal, New ERA, ICF International, 2017) The pregnancy related deaths per 100,000 live births was 281 for the period 1999-2006, which has come down to 259 for the period 2009-2016. These data indicate slow progress in maternal mortality reductions since 1999. But skilled births attendance and institutional births have improved remarkably. Delivery by SBA and institutional births has increased nearly seven folds from 1996 to 2016. The SBA delivery and institutional births is 58 percent and 57 percent respectively. These improvements are a result of strong Government of Nepal (GON) leadership, support from donors and technical assistance partners, and civic commitment and over a decade of investments. NDHS 2016 data also reveals that more than 50 percent of the under-five mortality happen in the first month of life indicating that preventing neonatal deaths could contribute substantially to a decline in under five mortality rates.

Nepal is promoting safe motherhood through expansion of birthing centers, increasing availability of skilled birth attendants (SBAs), and initiatives, such as providing free delivery care and transportation schemes to women delivering in a health facility (Family Health Division, 2002). For a holistic improvement in maternal and neonatal health (MNH), the country has implemented several national and sub-national programs. These include the Expanded Program in Immunization (EPI), Antenatal Care (ANC), Birth Preparedness Package (BPP), Postnatal Checkups (PNC), promotion of Skilled Birth Attendants (SBA), Family Planning (FP) services, Maternal and Neonatal Tetanus Elimination (MNTE), Community-Based Integrated Management of Childhood Illness (CB IMCI), and Infant and Young Child Feeding (IYCF) (GON, 2015).

The safe motherhood activities focus on behavioral changes by increasing awareness among pregnant women and their family members of the danger signs during the antenatal, delivery, and postnatal periods. The program also imparts knowledge on the importance of planning and preparing for delivery and postnatal care, and it seeks to increase a demand for and use of antenatal, delivery- related, and postnatal health services. Further, this program focuses on strengthening programs, including “iron intensification” and the “Birth Preparedness Package.” To combat the high MMR, it also promotes the use of oral misoprostol “matri surakshya chakki” (MSC) at home births, through Female Community Health Volunteers (FCHVs) to prevent postpartum hemorrhaging (PPH), a primary cause of maternal mortality in Nepal (Family Health Division, 2002).

The essential newborn care message at the community level includes initiating breastfeeding early, having skin-to-skin contact, using a new blade for cord cutting, applying the chlorhexidine (CHX) gel to cord stump immediately after cutting the cord, drying and wrapping, and delaying bathing until 24 hours. (Ministry of Health, 2016). It also emphasizes using clean materials and hand washing with soap before and during the handling of a newborn and treating the umbilical cord. Also, it teaches about appropriate handling of newborns and underweight babies and about infant and young child feeding (IYCF) practices. As a preventive measure, the program accentuates recognizing and seeking

1 prompt care when danger signs appear in neonates. The Community-based Integrated Management of Neonatal and Childhood Illness (CB-IMNCI) package has a strong neonatal service component that covers essential newborn care, treatment and management of sick newborns and referral services. Recently the GoN has also made in-patient newborn care services free of cost in public hospitals.

1.2 Survey Objectives

The overall objective of the study was to assess the maternal and newborn health care practices among RDW in Nepal. More specifically, the study attempted to assess the following areas of interests.

• Antenatal care attendance and receipt of various components of ANC. • Delivery care practices and receipt of various components of delivery care. • Postnatal care practices and receipt of various components of postnatal care related to the mother and newborn. • Knowledge and practice related to the use of CHX on the umbilical cord. • Knowledge of maternal and newborn danger signs. • Use of misoprostol in home deliveries in the absence of a SBA. • Immediate newborn care practices for those who were born at home. • Use of Postpartum family planning methods. • IYCF practices.

2 CHAPTER 2: METHODS

2.1 Study Population and Sample Size

The study team collected information on maternal and neonatal health from a sample of RDW. The RDW were confined to women ages 15-49 years old living in the selected districts who had given birth or had a pregnancy lasting at least seven months within the 15 months preceding the survey. RDW living in the selected households at the time of data collection but who were living in non- program districts when they were pregnant were excluded from the survey.

The survey sample size was calculated based on the DHS Annual report expected coverage in 2017, which estimated coverage of 80 percent based on routine data (MOHP and DOHS, 2015). The study was designed with 90 percent power and 95 percent confidence assuming a null hypothesis of no change in coverage from 56 percent as estimated in 2011(Nepal Family Health Program II, 2011). This sample size was increased by a design effect of 1.8 to account for clustering, then by a factor of 10 percent to account for miscarriages/abortions, and then by another 10 percent to account for non-response which gave a total sample per district of 168. Rounding the value, the required sample size for each district computed was 176 for 21 districts, equaling 3,696.

2.2 Survey Sample Selection

The survey team selected the study sample using multi-stage random sampling.

2.2.1 Selection of Districts All 58 out of 77 districts where CHX had been implemented at the facility and community level at the time of the survey were included in the sampling frame. The survey team selected the districts at random using sampling proportional to population size (PPS) and stratified by federal province (n=7) and ecological region (Mountain, Hill, and Terai), making a total of 21 districts selected at random to enable each province and ecological region to be represented. Two districts that rolled out CHX implementation during the former administrative system are now split across two provinces under the new administrative system. Nawalparasi (Terai ecological belt) is in Provinces 4 and 5 and Rukum (Hill ecological belt) is in Provinces 5 and 6. For the sake of sampling, the study team listed these two districts in the aforementioned provinces, with their populations halved. From those provinces not comprised of all three ecological regions, the survey team selected one district from the included zones by PPS, and the third district by random sampling, followed by PPS as before. The selected districts appear in Figure 1. From each district, the survet team recruited176 eligible RDW for the survey.

3 Figure 1 – Map of Study Districts

2.2.2 Selection of Clusters After selecting the districts in each province, the survey team followed the old administrative structure for smaller geographical units. From each selected district, the survey team selected eight Village Development Committees (VDCs, a lower administrative unit comprising of an average of nine wards) by PPS, selecting a total of 168 VDCs from the 21 districts. After selecting the VDCs, they survey team selected two wards from each VDC again selected using PPS; that is considered as the primary cluster in this survey. Ward populations vary considerably across VDCs. In the Mountain regions, ward populations are very low, while in the municipalities (urban) and Terai regions, populations are very high. For example, ward populations range from seven households per ward in Mountain districts to 5,000 households in a ward in Terai districts. Therefore, 16 clusters from each district was selected, for a total of 336 clusters from 21 districts. The list of selected clusters in each distric is shown in Appendix 1.

2.2.3 Selection of Households and Recently Delivered Women The study team conducted a census/listing of each household in the identified clusters to find the total number of households with RDW. After it reached the assigned district, the team visited the local bodies of government, including the District Health Office (DHO) and Local Development Office (LDO), where it presented a “help request/support” letter from the MOHP (Appendix 3). After informing the district-level authorities about the survey and purpose of visiting the district, the team then requested another “help/support” letter to present to local authorities of each selected cluster. With a support letter from local government bodies, it entered the clusters and started working on listing each residential household in each cluster. Segmentation of the cluster for the census was carried out for clusters having more than 600 households. After conducting the census, the team randomly selected from a hat the names of 11 households with RDW. If the cluster had less than the required 11 RDW, it selected the remaining samples from an adjoining ward by repeating the whole procedure of census/listing. If the selected households had more than one

4 RDW, the team randomly selected one RDW to approach for participation in the survey. The number of districts, clusters, and respondents per province appear in Table 2.2.3, and a summary of the sampling for each stage appears in Figure 2.

Figure 2 – Sample Selection

Table 2.2.3: Number of Districts, Clusters, and Respondents in Each Province Number of Number of Number of VDCs Federal Program Clusters Number o Districts Selected (8 Per

Province Districts Selected Selected District) (2 per VDC) Province 1 10 3 24 48 528 Province 2 6 3 24 48 528 Province 3 8 3 24 48 528 Province 4 7 3 24 48 528 Province 5 9 3 24 48 528 Province 6 10 3 24 48 528 Province 7 8 3 24 48 528 Total 58 21 168 336 3,696 Number of Ecological Belt Federal Program Districts Province Districts Mountain Hill Terai Selected Province 1 10 3 Sankhuwasabha Panchthar Morang Province 2 6 3 - - Mahhotari, Rautahat, Parsa Province 3 8 3 Sindhupalchowk Dhading Chitwan Province 4 7 3 Mustang Magdi Nawalparasi 9 3 - Palpa, Dang Province 5 Arghakhanchi Province 6 10 3 Jumla Salyan Dailekh Province 7 8 3 Bajhang Doti Kailali Total (7 58 21 5 7 9 Provinces) Total RDW 3,696 880 1,232 1,584

2.3 Survey Tools The study team adopted the survey tools used in the pilot survey (Nepal Family Health Program II, 2011) for the specific objectives of the follow up survey and translated the tools from English to Nepali. There were two sets of screening questionnaires and a structured questionnaire for RDW. The study team, in consultation with the Child Health Division of the Department of Health Service

5 (DOHS) and development partners, customized the tools that were used in the baseline survey. The survey questionnaire appears in Appendix 6.

2.3.1 Screening Form 1 The study team administered the first screening questionnaire at the household listing stage to the head of the household or a knowledgeable person in the household to determine the existence of resident women ages 15 to 49 years old who had been pregnant in the past two years. This form included collecting information on the usual number of woman ages 15 to 49 years old residing in the households, and their name, age, and marital status. For all ever-married women, further information was collected on their pregnancies in the past two years.

2.3.2 Screening Form 2 After confirming the total number of households in a cluster having women who had given birth in the past two years from screening 1, the field team selected a total of 20 households randomly (if the cluster had more than 20 eligible women) to proceed to a more detailed screening. The day after the team conducted the first screening, interviewers returned to 11 households, randomly selected from the 20 households, to approach each woman to get her written consent to participate in the survey, and to conduct a more detailed screening of her pregnancy/ies. All eligible women in the household were screened again to determine who was a RDW (pregnancy lasting at least seven months since Baishakh 2073/April 2017). This second screening form further confirmed her age, date of delivery, and the number of children she had. In cases where the household had more than one RDW, interviewers randomly selected a name from a hat to determine which RDW would complete the main questionnaire. If the household did not have an eligible RDW, the team randomly selected a twelfth household from the original 20 and administered the screening. If the household had an eligible RDW, but the RDW was not at home at the time the interviewer visited, the interviewer returned later, up to three times. If the RDW was still absent, no replacement was sought. If a RDW was present and refused to participate, a replacement RDW also was not sought.

2.3.3 RDW Questionnaire After confirming that a woman had had a pregnancy lasting at least seven months since Baishakh 2073 (April 2017), the interviewer administered the main questionnaire. This questionnaire included asking respondents about their background and socioeconomic characteristics; knowledge, receipt, and use of CHX; use and experiences of delivery care, immediate newborn care, and newborn care in the first month (Appendix 6).

2.4 Implementation of Survey

2.4.1 Field Survey Team Selection The study team selected 40 supervisors, 80 interviewers, and four quality controllers for the survey. It selected all field staff from the pool of New ERA field researchers who had worked previously on other similar surveys. The essential requirement for selecting field staff was that they possess relevant work experience in a similar area, work experience in rural communities, academic qualifications, languages known/spoken, and their rapport-building capacities. Since the protocol required interviews with RDW, the study team only recruited female interviewers. Supervisors were both male and female, while the four quality controllers were male. A detail list of core and field team members appears in Appendix 5.

2.4.2 Training for the Field Survey Team Training commenced immediately after the selection of field staff from April 2-13, 2017 and consisted of the standard activities used in the New ERA field staff training. Core survey team members docudcted the training. Officials from JSI, CAMRIS International, the Child Health Division,

6 and other stakeholders also were invited to give a detailed orientation about the pilot program and technical insights for the field teams. The training included:

• Objectives of the survey. • Reason for using a multi-stage cluster survey and a description of how to execute it. • Eligibility criteria when filling out the initial screening form. • Selection of households. • Rapport-building and how to gather consent. • The structure of the household questionnaire and how to ask questions correctly. • The purpose of each item included in the questionnaire. • Data recording. • Roles and responsibilities of the field team members. • An orientation on the CHX program. • An orientation on maternal health. • An orientation on neonatal and child health. • Mock interviews. • Sharing experiences.

2.4.3 Field Test of the Survey Instruments

To familiarize the field enumerators with the survey procedures and to identify the necessary changes required to the survey instruments, the study team conducted a pre-test near Kathmandu Valley (in the Kavrepalanchowk district). The pre-test assisted in improving the field procedures, and it familiarized the rest of the team members with potential survey cases. Based on the pre-test, the study team again reviewed and modified the questionnaires. Experiences also were shared among all team members so that the necessary information could be collected efficiently. The pre-test examined the adequacy of the questions, the clarity/wording of questions, the adequacy of possible responses (pre-coded), the sequence/flow of questions, the skip patterns, and questionnaire administration techniques.

2.5 Refresher Training and Data Collection

2.5.1 First Phase of Data Collection The initial proposed plan for field work departure was April 15, 2017, but due to the local election code of conduct, it was postponed until the completion of the local election. Since the election was planned to be held in two phases, the field work was conducted in two phases. The field teams first went to the districts where the first round of the election was held. For this reason, New ERA delayed mobilization of the field team for over one month, and it held refresher training from May 21-26, 2017. Due to the month-long delay, a few (n = 16) field team members dropped out due to personal reasons, and the study team removed a few members due to their performance. Finally, 36 field teams were formed with one supervisor and two interviewers in each team.

The study team conducted the first phase of the data collection in three districts (Chitwan, Nawalparasi, and Dhading) in Central Nepal under the direct supervision of the core survey team members representing CAMRIS International, JSI, and New ERA between May 27 and June 2, 2017.

2.5.2 Second Phase of Data Collection Due to the shift of the second phase of the election from June 14 to June 23, then again to June 28, New ERA postponed data collection activities and put the team on hold for 14 days after completing

7 data collection in nine districts. Thestudy team conducted the second phase of data collection between July 1, 2017 and August 6, 2017.

8 2.6 Quality Control

The New ERA central office closely monitored the progress of the field work. The field teams immediately sent data collected after completion of the survey. For this, New ERA mobilized two runners throughout the survey period to bring the collected data from the field. All teams were provided a cluster summary sheet and asked to send the sheet after completion of each cluster via the internet. The filled questionnaires were edited at two levels - first, by the field supervisors in the field, and second, by the staff at New ERA who checked the questionnaires thoroughly before they were sent to the data entry department.

The study team took the following measures during the data collection period to ensure that it gathered valid and reliable data:

• Checked the correct identification of the RDW. • Ensured each questionnaire was filled in correctly by checking it before terminating each interview. • Checked questionnaires for consistency and errors. • Verified that interviewers wrote their names on the questionnaires, so that it would be possible for clarification to be provided if certain information was unclear during the data coding and entry period.

With the aim of monitoring data collection and further strengthening data quality, New ERA core team members also conducted several phases of fieldwork supervision throughout the fieldwork period. The team leader, research officers, a research assistant, a data supervisor, and four quality controllers supervised the field work. During monitoring, the core study team members verified the consistency and accuracy of the completed questionnaire, which was already checked by the supervisors assigned to each team. Group meetings and interaction with the team were conducted and feedback was provided. Representatives from JSI and CAMRIS International also closely supervised and monitored the progress of the field work.

The core team members checked the quality of data received from the field daily. They closely reviewed the list of data errors, notes from the field, and responses under the “others” categories. The core team members checked and re-confirmed the error messages for each cluster. The core study team provided the team members with regular feedback, and when necessary, asked them to explain inconsistencies.

2.7 Data Entry, Cleaning, and Analysis

Immediately after the mobilization of the field teams, a data programmer developed in FoxPRO a software package for data entry. The computer programming for data entry and analysis was based on questionnaires and expected outputs. Several quality-check mechanisms, such as range checks and skip instructions, were developed to detect errors during the data entry stage. New ERA started processing and entering the data soon after receiving the information from the field. Before entering data into the computer, all completed questionnaires were thoroughly checked. Each questionnaire was double-entered by two different trained New ERA employees, and the two copies were validated using an editing program in FoxPRO. Errors in data entry were identified using consistency and logic checks of the two copies and followed by manual checking of questionnaires. A data programmer closely monitored the data entry activities.

The study team analyzed the data at the individual level using Stata version 12. A wealth index score, as a measure of socio-economic status, was constructed for each woman using the first principal

9 component of household assets and characteristics (Pritchett, Filmer D., 2001). These included household ownerships of assets, such as a radio, bicycle, mobile telephone, television, fridge, furniture, computer, and car; the type of materials used to construct the floor, walls, and roof of the dwelling; and the type of water and toilet facilities the household used. The respondents were ranked according to this total wealth score and divided into quintiles. The team calculated means (or inter-quartile ranges (IQR) for non-normal data) and proportions of respondent background characteristics, knowledge and use of CHX, pregnancy and delivery characteristics, and newborn care behaviors. The team used a logistic regression analysis to estimate the difference in the likelihood of CHX being applied between home and facility deliveries while accounting for possible confounders. It used Svy1 commands to account for the clustered sampling design.

2.8 Research Ethics

Ethical clearance for the survey was obtained from Nepal Health Research Council (Appendix 4). Before the interviews, a letter from the MOHP/Child Health Division and New ERA was presented and the purpose of the study was explained to each participant. The respondents were given the opportunity to ask questions regarding the survey and to decide whether to participate. Before the interview, the field team obtained a written informed consent to participate from each respondent. The study team designed the survey procedure to protect participants’ privacy, allowing for anonymous and voluntary participation. Screening or consent forms, which contained names, were not stored with the main questionnaires. Anonymous electronic data were kept on password- protected computers. The completed consent forms and questionnaires were stored in New ERA’s data entry office in a locked cabinet and will be disposed of three years after the survey completion.

1Survey command in Stata software (www.stata.com)

10 CHAPTER 3: SAMPLE CHARACTERISTICS

This chapter provides a demographic and socio-economic picture of the study population. The field team visited 55,247 households and identified 72,007 women of reproductive age. Of these, 6,258 had been pregnant in the previous two years. Of these, 3,664 women reside in districts where CHX program had been implemented during their pregnancy and had a pregnancy that had lasted at least 7 months (i.e., ended in a live birth or stillbirth) since Baishak 2073 (April 2017). Of the 3,664 women who were eligible to participate in the study, a total of 3,661 agreed to participate.

3.1 Socio-Demographic Characteristics of the Respondents

Table 3.1: Percent Distribution of RDW by Socio-demographic Characteristics Characteristics n % Ecological Zone Mountain 847 23.1 Hill 1,406 38.4 Terai 1,408 38.5 Province Province 1 528 14.4 Province 2 528 14.4 Province 3 528 14.4 Province 4 494 13.5 Province 5 528 14.4 Province 6 528 14.4 Province 7 527 14.4 Age 15-19 597 16.3 20-24 1,529 41.8 25-29 939 25.6 30-34 389 10.6 35-49 207 5.7 Median age (age in years) 23 - Literacy Status Literate1 3,010 82.2 Illiterate2 651 17.8 Education Level3 No education4 687 18.8 Primary5 458 12.5 Secondary6 1,396 38.1 SLC and above 1,120 30.6 Ethnicity Brahmin/Chhetri 1,342 36.7 Dalit 657 17.9 Janajaties 1,251 34.2 Other Terai Castes and Religious Minorities 411 11.2 Total 3,661 100.0 1Includes those who have attended secondary school or higher or who can read a complete sentence 2Includes those who have never been to school or who can’t read a complete sentence or can’t read at all 3Includes those who have attended school and completed the highest level 4Includes those who have never attended school 5Includes those who have completed 0-4 years of school 6Includes those who have completed 5-9 years of school

11 3.2 Housing Characteristics

Table 3.2: Percent Distribution of Housing Characteristics of RDW

Characteristics n % Flooring Material Earth/sand 2,322 63.4 Animal Dung 258 7.0 Rudimentary floor/Wood planks 47 1.3 Wood 31 0.8 Ceramic tiles 10 0.3 Cement 922 25.2 Carpet 61 1.7 Other 10 0.4 Roofing Materials Thatch/palm leaf 302 8.2 Wood planks 2 0.1 Galvanized sheet 1,692 46.2 Calamine/cement fiber 18 0.5 Ceramic tiles 899 24.6 Cement 496 13.5 Mud 55 1.5 Mud and wood 192 5.2 Other 5 0.1 Outer Wall Materials Cane/palm/trunks 27 0.7 Mud/sand 225 6.1 Bamboo with mud 440 12.0 Stone with mud 1,629 44.5 Reused wood 32 0.9 Galvanized metal sheet 152 4.2 Cement 789 21.6 Stone with lime/cement 70 1.9 Bricks 205 5.6 Cement blocks 46 1.3 Wood planks/shingles 38 1.0 Other 8 0.2 Total 3,661 100.0

12 3.3 Household Possessions

Table 3.3: Percent Distribution of Household Possessions of RDW Characteristics# n % Household Possessions Electricity (Grid/Solar) 3,497 95.5 Mobile phone 3,530 96.4 Landline phone 114 3.1 Television 1,787 48.8 Radio 1,278 34.9 Refrigerator/Fridge 489 13.4 Table 2,080 56.8 Chair 2,223 60.7 Bed 3,357 91.7 Sofa 512 14.0 Cupboard 1,719 47.0 Computer 382 10.4 Wall clock 1,178 32.2 Electric fan 1,321 36.1 Means of Transportation Bicycle/Rickshaw 1,041 28.4 Motorcycle 711 19.4 Tempo (3 Wheeler) 23 0.6 Animal drawn cart 78 2.1 Car/truck/tractor (4 wheeler) 85 2.3 Total 3,661 100.0 #Multiple responses. Responses were prompted.

3.4 Sources of Drinking Water

Table 3.4: Percent Fistribution of Source of Drinking Water Reported by RDW Source of Drinking Water n % Improved Sources Piped into dwelling 97 2.6 Piped to yard/plot 640 17.5 Piped to neighbor 44 1.2 Public tap/standpipe 961 26.2 Tube well or borehole 856 23.4 Protected well 171 4.7 Protected spring 578 15.8 Bottled water 4 0.1 Total improved sources 3,351 91.5 Non-improved Sources Unprotected well 101 2.8 Unprotected spring 122 3.3 Tanker/truck 2 0.1 Cart with small tank 1 0.0 Surface water1 83 2.3 Other 1 0.0 Total non-improved sources 310 8.5 Total 3,661 100.0 1Surface water includes river, dam, lake, pond, stream, canal, irrigation canal, and so on.

13 3.5 Types of Toilet Facility

Table 3.5: Percent Distribution of Types of Toilet Facility of RDW

Types of Toilet Facility n % Improved facility Flush to piped sewer system 23 0.6 Flush to septic tank 2,717 74.2 Flush to pit latrine 309 8.4 Ventilated improved/pit latrine 30 0.8 Pit latrine with slab 253 6.9 Composting toilet 9 0.2 Total improved facility 3,341 91.1 Non-improved facility Flush to somewhere else 5 0.1 Flush, don't know where 3 0.1 Pit latrine without slab/open pit 27 0.7 No facility/bush/field 267 7.3 Other 18 0.5 Total non-improved facility 320 8.7 Total 3,661 100.0

3.6 Household Wealth Quintiles

Table 3.6: Percent Distribution of RDW by Wealth Quintile Wealth Quintile n % Lowest 731 20.0 Second 733 20.0 Middle 729 19.9 Fourth 731 20.0 Highest 737 20.1 Total 3,661 100.0

14 CHAPTER 4: RDW KNOWLEDGE ABOUT FCHV AND HEALTH MOTHER'S GROUP

The FCHV Program initiated in 1988 was designed to enhance Nepal’s primary health care network through community participation and expanded outreach by local women working voluntarily. Currently, there are 52,000 FCHVs assisting with primary health care activities and acting as a bridge between government health programs and the local community (Ministry of Health and Population, Annual Report, 2013). Since inception, FCHVs have served as frontline local health resource persons who provide community-based health education and services in rural areas with a special focus on maternal, newborn and child health, and family planning issues. Primarily, they have been mobilized for counseling pregnant women on ANC, delivery care, PNC, and newborn care. In this context, the study collectd information related to various aspects of FCHV services, including each respondent's utilization of their services in the last pregnancy. This chapter presents general findings of the survey regarding these issues.

4.1 Recently Delviered Women’s Knowledge about Female Community Health Volunteers (FCHVs)

Table 4.1: Percent Distribution of RDW, By Their Background Characteristics, Who Know a FCHV and Who Met a FCHV During Their Last Pregnancy Know FCHV Met FCHV During Their Last (N=3,661) Pregnancy (N=3,200)1 N % n % Ecological Zone * Mountain 763 90.1 466 61.1 Hill 1,289 91.7 863 67.0 Terai 1,148 81.5 695 60.5 Province * * Province 1 439 83.1 196 44.6 Province 2 394 74.6 257 65.2 Province 3 443 83.9 296 66.8 Province 4 420 85.0 214 51.0 Province 5 491 93.0 334 68.0 Province 6 506 95.8 371 73.3 Province 7 507 96.2 356 70.2 Age * ns 15-19 498 83.4 311 62.4 20-24 1,342 87.8 847 63.1 25-29 824 87.8 546 66.3 30-34 345 88.7 206 59.7 35-49 191 92.3 114 59.7 Literacy Status ns * Literate 2,627 87.3 1637 62.3 Illiterate 573 88.0 387 67.5 Education Level ns ns No schooling 606 88.2 402 66.3 Primary 411 89.7 265 64.5 Some secondary 1,232 88.3 785 63.7 SLC and above 951 84.9 572 60.1 Ethnicity * * Brahmin/Chhetri 1,214 90.5 790 65.1 Dalit 587 89.3 394 67.1 Janajaties 1,095 87.5 647 59.1 Other Terai Castes and Religious Minorities 304 74.0 193 63.5 Wealth Quintile * * Lowest 680 93.0 456 67.1 Second 681 92.9 443 65.1 Third 645 88.5 421 65.3 Fourth 616 84.3 401 65.1 Highest 578 78.4 303 52.4 Total 3,200 87.4 2,024 63.3 95% confidence interval (85.5-89.1) (60.7-65.7) *Significant at <0.05 level ns= not significant

15 1Total includes those RDW who knew FCHV 4.2 Health Mother's Groups

Table 4.2: Percent Distribution of RDW Who Know of a Health Mother's Group in Her Area and Attending the meeting During Their Last Pregnancy Knowledge of Health Attended Mothers Group Mothers Group (N=3,661) Meeting (N=1,224)1 n % n % Ecological Zone * * Mountain 312 36.8 118 37.8 Hill 529 37.6 237 44.8 Terai 383 27.2 98 25.6 Province * * Province 1 55 10.4 15 27.3 Province 2 115 21.8 27 23.5 Province 3 205 38.8 70 34.1 Province 4 114 23.1 19 16.7 Province 5 182 34.5 70 38.5 Province 6 279 52.8 101 36.2 Province 7 274 52.0 151 55.1 Age * ns 15-19 189 31.7 62 32.8 20-24 538 35.2 206 38.3 25-29 323 34.4 118 36.5 30-34 116 29.8 44 37.9 35-49 58 28.0 23 39.7 Literacy Status * ns Literate 982 32.6 362 36.9 Illiterate 242 37.2 91 37.6 Education Level ns ns No schooling 245 35.7 99 40.4 Primary 150 32.8 43 28.7 Some secondary 459 32.9 174 37.9 SLC and above 370 33.0 137 37.0 Ethnicity * * Brahmin/Chhetri 552 41.1 223 40.4 Dalit 238 36.2 94 39.5 Janajaties 329 26.3 105 31.9 Other Terai Castes and Religious Minorities 105 25.5 31 29.5 Wealth Quintile * * Lowest 276 37.8 111 40.2 Second 283 38.6 120 42.4 Third 238 32.6 95 39.9 Fourth 220 30.1 73 33.2 Highest 207 28.1 54 26.1 Total 1,224 33.4 453 37.0 95% confidence interval (30.1-36.9) (33.5-40.7) *Significant at <0.05 level ns= not significant 1Total includes those RDW who knew HMG

Table 4.3: Percent Distribution of Topics Discussed in HMG Meetings Reported by RDW Types of Topics Discussed# n % Nothing 1 0.2 CHX 135 29.8 Newborn Care 138 30.5 Child Care 117 25.8 Immunization 184 40.6 Nutrition 362 79.9 Institutional delivery 215 47.5 About hygiene/sanitation 27 6.0 Others 27 6.0 Don't remember 7 1.5 Total1 453 #Multiple responses. Responses were not prompted. 1Total includes RDW who reported attending HMG

17 CHAPTER 5: ANTENATAL CARE

ANC is an essential component of maternal care for preventing complications that may occur during pregnancy, delivery, and after delivery (WHO, 2016). Nepal follows the World Health Organization's recommendation of initiation of ANC within the first four months of pregnancy and at least four ANC visits during an uncomplicated pregnancy (World Health Organization, 2004). The MOHP recommends focused ANC visits at the fourth, sixth, eighth, and ninth month of pregnancy (MOHP, 2015). In Nepal, ANC services are available from all public health facilities. FCHVs conduct awareness-raising activities and iron-folic acid distribution at the community level. Furthermore, the government has initiated the Aama program (free maternity care and transport incentives to promote four ANC visits and institutional delivery) since 2009 (Family Health Division, 2012).

5.1 Antenatal Care Service Utilization

Table 5.1: Percent Distribution of the Number of ANC Visits and Month of Pregnancy When Received the First ANC Through Health Workers Reported by RDW n % Number of ANC visits No ANC visit 123 3.4 1 78 2.1 2-3 670 18.3 4 1,526 41.7 More than 4 1,264 34.5 Mean number of ANC visits during the entire pregnancy period 4.49 Total 3,661 100.0 Number of months pregnant at time of first ANC visit 1-3 months 1,622 45.8 4 months 1,513 42.8 5-6 months 319 9.0 7+ months 84 2.4 Median month of pregnancy when sought first ANC 3.55 Total1 3,538 100.0 1Total includes only those RDW who had ANC visit.

Table 5.2: Percent Distribution of Antenatal Care Provider and Receiving At Least One Antenatal Care From a Skilled Provider According to Background Characteristics of RDW Antenatal Care Provider Received ANC (N=3,538)2 From a Skilled Background Characteristics Provider1 Doctor Nurse/ANM Others (N=3,538)2 N % % % % Ecological Zone * * * * Mountain 773 32.6 62.5 4.9 95.1 Hill 1,291 27.8 66.6 5.3 94.4 Terai 1,320 50.1 47.1 2.4 97.2 Province * * * * Province 1 450 35.8 51.3 12.6 87.0 Province 2 466 49.2 46.3 3.7 95.5 Province 3 497 50.0 47.1 2.5 97.1 Province 4 460 47.3 48.5 4.2 95.8 Province 5 509 35.7 63.5 0.8 99.2 Province 6 497 17.7 79.1 3.1 96.9 Province 7 505 27.8 70.3 1.7 98.1 Age ns * * ns 15-19 558 6.0 59.5 3.9 95.7 20-24 1,424 36.6 59.2 3.9 95.8 25-29 888 41.0 55.5 3.5 96.5 30-34 350 38.0 56.3 5.4 94.3 35-49 164 29.4 63.3 6.8 92.7 Literacy Status * ns ns * Literate 2,836 39.9 56.1 3.7 96.0 Illiterate 548 25.1 68.5* 6.0 93.7 Education Level * * * * No schooling 580 27.0 66.7 5.8 93.7 Primary 412 27.6 67.3 4.6 94.9 Some secondary 1,315 34.1 61.8 3.9 95.9 SLC and above 1,077 51.2 45.5 3.1 96.7 Ethnicity * * * * Brahmin/Chhetri 1,289 38.3 59.1 2.5 97.4 Dalit 616 29.2 67.5 3.1 96.7 Janajaties 1,112 37.8 55.2 6.6 93.1 Other Terai Castes and Religious Minorities 367 47.0 48.8 3.4 95.8 Wealth Quintile * * * * Lowest 644 16.2 16.2 6.1 93.9 Second 649 24.7 24.7 6.6 93.1 Third 676 33.6 33.6 3.6 96.2 Fourth 690 44.4 44.4 3.6 96.0 Highest 725 66.4 66.4 0.8 98.9 Total 3,384 37.5 58.2 4.1 95.6 95% Confidence Interval (34.9-40.0) (55.6-60.7) (3.1-5.3) (94.4-96.6) *Significant at <0.05 level ns= not significant 1Skilled Provider includes Doctor, Nurse and ANM. 2Total includes those RDW who went for at least one ANC checkup.

Table 5.3: Percent Distribution of RDW Who Attended ANC During the Recommended Months of Pregnancy According to Background Characteristics Percentage of RDW who attended ANC (N=3,538)2 In the 4th In the 4th, During all Background Characteristics No. of In the 4th and 6th 6th, and 8th Specified Women Month Months Months Months1 Ecological Zone * * * * Mountain 813 69.9 59.3 51.2 44.5 Hill 1,367 66.9 58.2 52.9 47.4 Terai 1,358 59.7 52.4 45.9 40.2 Province * * * * Province 1 517 67.1 57.3 51.5 46.6 Province 2 488 51.0 41.4 33.8 26.6 Province 3 512 63.9 53.9 45.9 36.9 Province 4 480 52.9 43.8 38.1 32.7 Province 5 513 69.0 63.0 57.5 52.0 Province 6 513 66.5 56.7 49.7 44.8 Province 7 515 81.7 75.7 70.7 66.4 Age ns ns ns * 15-19 583 63.6 54.2 45.3 38.4 20-24 1,487 64.4 56.6 50.8 44.9 25-29 920 67.0 58.0 52.5 46.8 30-34 371 62.5 54.2 48.2 44.2 35-49 177 66.1 53.7 45.8 39.0 Literacy Status ns * * * Literate 2,953 65.5 57.4 51.1 45.5 Illiterate 585 61.5 50.3 43.2 36.1 Education Level * * * * No schooling 619 62.7 50.9 43.0 36.2 Primary 434 58.5 47.9 42.6 37.3 Some secondary 1,371 65.6 57.3 50.3 43.8 SLC and above 1,114 67.4 61.0 55.9 51.1 Ethnicity * * * * Brahmin/Chhetri 1,323 68.5 62.2 56.5 52.2 Dalit 637 63.6 54.5 47.6 41.8 Janajatis 1,195 64.9 53.9 47.4 40.1 Other Terai Castes and Religious Minorities 383 53.8 45.4 38.4 31.3 Wealth Quintile ns ns ns ns Lowest 686 65.3 55.4 48.0 41.8 Second 697 65.0 54.4 47.9 41.9 Third 703 65.0 56.0 49.6 44.5 Fourth 719 64.3 57.7 52.2 45.2 Highest 733 64.5 57.3 51.3 46.2 Total 3,538 64.8 56.2 49.8 44.0 95% Confidence Interval (62.9-66.7) (54.2-58.2) (47.8-51.9) (41.9-46.0) *Significant at <0.05 level ns=not significant 1Received ANC at 4, 6, 8 and 9 months 2Total includes those RDW who went for at least one ANC checkup.

Table 5.4: Percent Distribution of Place of Last ANC Visit Reported by RDW Place of Last ANC Checkups n % No ANC visit 123 3.4 Government Hospital 1,272 34.7 Primary Health Care Centre 195 5.3 Health Post/Sub-health Post 1,476 40.3 Urban Health Clinic 4 0.1 PHC/Outreach Clinic 76 2.1 Private Hospital/Clinic/Nursing Home/NGOs 478 13.1 Medical Shop/Pharmacy 5 0.1 Community Health Unit 16 0.4 Hospital in India 11 0.3 Others 2 0.1 Missing 3 0.1 Total 3,661 100.0

5.2 Types of Services and Counseling Received During Antenatal Care (ANC)

Table 5.5: Percent Distribution of RDW Receiving Specific Antenatal Services Among Those Who Received ANC Services According to Background Characteristics

Among Women Who Received ANC, % With Selected Services# No. of Women Background Blood Blood Urine Who Received Abdomen Weight Characteristics Pressure Sample Sample ANC Axamined Measured Measured Taken Taken Ecological Zone ns ns * * * Mountain 813 98.9 96.7 94.6 75.6 85.4 Hill 1,367 98.2 96.0 97.4 73.5 82.7 Terai 1,358 98.5 96.5 96.4 82.1 86.7 Province ns * * * * Province 1 517 99.0 96.1 98.1 73.3 83.2 Province 2 488 96.9 93.0 92.8 71.7 79.9 Province 3 512 98.8 96.3 98.0 80.1 85.2 Province 4 480 98.8 96.7 97.5 79.8 86.3 Province 5 513 97.7 98.1 98.1 82.1 84.4 Province 6 513 98.6 96.7 94.9 70.6 87.7 Province 7 515 99.4 97.3 95.0 83.5 87.2 Age ns * Ns * * 15-19 583 99.1 97.1 95.7 77.4 84.7 20-24 1,487 98.5 96.8 96.6 78.3 87.0 25-29 920 98.6 96.6 96.8 78.5 84.7 30-34 371 98.4 94.3 96.2 74.7 80.1 35-49 177 96.0 92.7 94.4 68.4 78.0 Literacy Status * * * * * Literate 2,953 98.8 97.1 97.4 80.1 86.5 Illiterate 585 96.8 92.3 91.1 63.1 76.8 Education Level * * * * * No schooling 619 96.0 90.8 91.3 64.8 75.9 Primary 434 98.6 95.6 94.9 68.2 80.9 Some secondary 1,371 98.8 96.8 96.8 75.8 84.6 SLC and above 1,114 99.5 99.1 99.2 89.7 91.7 Ethnicity ns * * * * Brahmin/Chhetri 1,323 98.9 98.3 96.4 83.8 88.4 Dalit 637 98.6 96.5 97.0 70.5 84.3 Janajaties 1,195 98.3 95.1 97.0 74.3 81.6 Other Terai Castes and 383 97.4 93.2 93.0 75.5 83.8 Religious Minorities Wealth Quintile ns * * * * Lowest 686 98.1 94.6 93.6 62.8 76.5 Second 697 97.7 94.3 95.7 69.3 78.6 Third 703 98.2 96.6 96.3 74.7 84.8 Fourth 719 98.7 97.5 97.4 86.1 89.7 Highest 733 99.6 98.5 98.6 92.4 93.9 Total1 3,538 98.5 96.3 96.4 77.3 84.9 95% Confidence Interval (97.9-98.9) (95.5-97.0) (95.4-97.1) (75.1-79.4) (93.0-86.5) #Multiple responses. Responses were prompted. *Significant at <0.05 level ns= not significant 1Total includes only those RDW who had at least one ANC visit.

Table 5.6: Percent Distribution of the Types of Counselling Received From Health Workers During ANC Visit Reported by RDW Types of Counseling# n % Danger sign during pregnancy 2,727 77.1 Delivery at a health facility 3,108 87.8 Delivering with a skilled birth attendant 2,465 69.7 Arranging emergency transport for delivery 1,994 56.4 Arranging money for delivery 2,241 63.3 Where to go for emergency obstetric care 2,364 66.8 Identifying person to accompany mother to health facility 1,756 49.6 Identifying potential blood donor 1,190 33.6 Applying CHX to cord stump immediately after birth 1,512 42.7 Applying nothing to the cord after applying CHX 1,431 40.4 Danger sign during delivery 2,144 60.6 Post-natal visit to a health facility or outreach clinic 1,904 53.8 Danger sign during postpartum period 2,000 56.5 Hand washing with soap and water before touching the newborn baby 2,322 65.6 Wrapping the newborn with clean and dry cloth immediately after birth 2,747 77.6 Do not bathe the newborn within 24 hours of birth 2,636 74.5 Breastfeeding the newborn within one hour of birth 2,863 80.6 Exclusive breastfeeding to the child for 6 months 2,903 82.1 Continue breastfeeding the child till 2 years 2,538 71.7 Danger sign in newborn 2,000 56.5 Skin-to-skin contact (Placing the baby on the mother's chest or belly immediately after birth) 2,353 66.5 Maternal cash incentive scheme 2,609 73.7 Information on immunization schedule 2,886 81.6 Postpartum family planning 2,046 57.8 Total1 3,538 #Multiple responses. Responses were prompted. 1Total includes only those RDW who went for ANC checkups.

22 5.3 Tetanus Toxoid Immunization

Table 5.7: Percent Distribution of RDW Who Received At Least One TT Injection, and Who Received Two or More TT Injections During Their Pregnancy By Background Characteristics Received At Least One TT Received At Least Two TT Background Characteristics Vaccine (N=3,538)1 Vaccines (N=3,464)2 n % n % Ecological Zone * * Mountain 789 97.0 522 66.2 Hill 1,336 97.7 947 70.9 Terai 1,341 98.7 1,022 76.3 Province Ns * Province 1 501 96.9 385 76.8 Province 2 479 98.2 359 74.9 Province 3 501 97.9 419 83.6 Province 4 472 98.3 309 65.7 Province 5 507 98.8 350 69.0 Province 6 496 96.7 304 61.3 Province 7 510 99.0 365 71.6 Age * * 15-19 572 98.1 490 85.8 20-24 1,459 98.1 1,100 75.4 25-29 906 98.5 579 63.9 30-34 361 97.3 220 61.1 35-49 168 94.9 102 60.7 Literacy Status * * Literate 2,904 98.3 2,121 73.1 Illiterate 562 96.1 370 65.8 Education Level * * No schooling 596 96.3 391 65.6 Primary 416 95.9 274 65.9 Some secondary 1,346 98.2 969 72.1 SLC and above 1,108 99.5 857 77.3 Ethnicity * ns Brahmin/Chhetri 1,305 98.6 930 71.3 Dalit 619 97.2 426 68.9 Janajaties 1,167 97.7 868 74.4 Other Terai Castes and Religious Minorities 375 97.9 267 71.2 Wealth Quintile * * Lowest 659 96.1 440 66.8 Second 681 97.7 488 71.7 Third 687 97.7 496 72.4 Fourth 711 98.9 500 70.3 Highest 728 99.3 567 77.9 Total 3,466 98.0 2,491 71.9 95% Confidence Interval (97.4-98.4) (70.1-73.7) *Significant at <0.05 level ns= not significant 1Total includes only those RDW who had at least one ANC visit. 2Total includes only those RDW who had received TT injection.

23 5.4 Intake of Iron Folic Acid Tables and Deworming Tablets

Table 5.8: Percent Distribution of RDW Who Took Iron Folic Acid Tablets and Intestinal Parasite Drugs During Their Pregnancy By Background Characteristics Took At Least 180 Recommended Background Characteristics Took Iron Folic Iron Folic Acid Took Intestinal Acid Tablets Tablets Parasite Drugs (N=3,661) (N=3,496)1 (N=3,538)2 n % n % n % Ecological Zone ns * * Mountain 807 95.3 411 50.9 738 90.8 Hill 1,356 96.4 788 58.1 1,277 93.4 Terai 1,333 94.7 711 53.3 1,168 86.0 Province * * * Province 1 513 97.2 263 51.3 461 89.2 Province 2 468 88.6 206 44.0 373 76.4 Province 3 509 96.4 299 58.7 449 87.7 Province 4 480 97.2 278 57.9 436 90.8 Province 5 509 96.4 265 52.1 485 94.5 Province 6 503 95.3 259 51.5 486 94.7 Province 7 514 97.5 340 66.1 493 95.7 Age * ns * 15-19 577 96.6 293 50.8 515 88.3 20-24 1,471 96.2 822 55.9 1,346 90.5 25-29 902 96.1 511 56.7 838 91.1 30-34 366 94.1 595 53.3 335 90.3 35-49 180 87.0 89 49.4 149 84.2 Literacy Status * * * Literate 2,930 97.3 1,645 56.1 2,694 91.2 Illiterate 566 86.9 265 46.8 489 83.6 Education Level * * * No schooling 597 86.9 282 47.2 519 83.8 Primary 429 93.7 188 43.8 382 88.0 Some secondary 1,361 97.5 715 52.5 1,245 90.8 SLC and above 1,109 99.0 725 65.4 1,037 93.1 Ethnicity * * * Brahmin/Chhetri 1,318 98.2 826 62.7 1,246 94.2 Dalit 626 95.3 300 47.9 577 90.6 Janajaties 1,190 95.1 634 53.3 1,057 88.5 Other Terai Castes and Religious Minorities 362 88.1 150 41.4 303 79.1 Wealth Quintile * * ns Lowest 676 92.5 327 48.4 617 89.9 Second 963 94.5 347 50.1 631 90.5 Third 693 95.1 362 52.2 634 90.2 Fourth 707 96.7 413 58.4 652 90.7 Highest 727 98.6 461 63.4 649 88.5 Total 3,496 95.5 1,910 54.6 3,183 90.0 95% Confidence Interval (94.5-96.3) (52.4-56.8) (88.8-91.0) *Significant at <0.05 level ns= not significant 1Total includes only those RDW who took iron folic acid tablets during pregnancy. 2Total includes only those RDW who had at least one ANC visit.

24 5.5 Knowledge about Danger Signs and Service Seeking Behavior During Pregnancy

Table 5.9: Percent Distribution of Awareness of Danger Signs During Pregnancy and Places to Go When Those Signs Persist Reported by RDW n % Signs During Pregnancy That Require Attention# Blurred vision 359 9.8 Severe lower abdominal pain 2,591 70.8 Severe headache 1,144 31.2 Convulsion 487 13.3 Swelling of hands and face 814 22.2 Vaginal bleeding 2,442 66.7 No fetal movement inside womb 1,038 28.4 While fluids/vaginal discharge 235 6.4 Fever 67 1.8 Nausea/Vomiting 87 2.4 Dizziness 102 2.8 Others1 91 2.5 Do not know 78 2.1 Know at least three danger signs out of 6 danger signs1 3,288 89.8 Know more than three danger signs out of 6 danger signs1 254 6.9 None 119 3.3 Places to Go in Case of Danger Signs# Government hospital 2,925 79.9 Primary Health Care Centre 352 9.6 Urban health clinic 58 1.6 Health post/Sub-health post 2,502 68.3 Community health unit 27 0.7 PHC/Outreach clinic 131 3.6 Private hospital/Clinic/Nursing home/NGOs 1,524 41.6 Medical shop/pharmacy 230 6.3 FCHV 294 8.0 Traditional healers 53 1.4 Treatment at home 1 0.0 No need of treatment 1 0.0 Others2 1 0.0 Don't know 3 0.1 Missing 1 0.0 Total 3,661 #Multiple responses. Responses were not prompted. 1The 6 danger signs includes: blurred vision, severe lower abdominal pain, severe headache, convulsion, swelling of hands and face, and vaginal bleeding,

25 5.6 Danger Sign Encountered During Pregnancy and Management of the Problems

Table 5.10: Percent Distribution of RDW Who Encountered a Danger Sign During Pregnancy and Actions Taken for the Problems Encountered Types of Problem during Pregnancy and Action Taken to Solve n % Encountered a Danger Sign During Pregnancy Encountered at least three problems out of six problems3 1,339 36.7 Encountered more than three problems out of six problems3 86 2.3 No problem 2,222 60.9 Total1 3,647 100.0 Types of Problem Encountered# Blurred vision 420 11.5 Severe lower abdominal pain 707 19.4 Severe headache 430 11.8 Convulsion 202 5.5 Swelling of the limbs, body or face 489 13.4 Any vaginal spotting or bleeding 180 4.9 Total2 1,425 Action Taken to Solve the Problem* Government hospital 405 28.4 Primary health care center 80 5.6 Urban health clinic 4 0.3 Health post/Sub-health post 474 33.3 Community health unit 6 0.4 Outreach clinic 14 1.0 Private hospital/Clinic/Nursing home 305 21.4 Medical shop/Pharmacy 38 2.7 FCHV 27 1.9 Traditional birth attendant 2 0.1 Traditional healers 14 1.0 Treatment at home 68 4.8 No need of treatment 248 17.4 Others 2 0.1 Missing 3 0.2 Total2 1,425 #Multiple responses. Responses were prompted. *Multiple responses. Responses were not prompted. 1Total includes only those RDW who had a live birth. 2Total includes only those RDW with live birth who have encountered problem during last pregnancy. 3The six problem include blurred vision, severe lower abdominal pain, severe headache, convulsion, swelling of the limbs, body or face, and any vaginal spotting or bleeding.

26 5.7 Birth Preparedness

Table 5.11: Percent Distribution of RDW Reporting Different Types of Birth Preparedness#

N % Type of Birth Preparedness Activity# Saved money 2,470 76.0 Arranged for transport 722 22.2 Identified health facility 455 14.0 Found blood donor 130 4.0 Identified health worker 65 2.0 Arranged cloth 2,356 72.5 Arranged food 520 16.5 Any preparation 3,250 88.8 No preparation 411 11.2

At least 3 types of preparation out of 6 types1 2,270 62.0 4-5 types of preparation out of 6 types1 914 25.0 All 6 types of preparation 18 0.5 Total 3,661 # Multiple Responses. Responses were not prompted. 1The six types of birth preparedness include saved money, arranged for transportation, identified health facility, found blood donor, identified health worker and arranged cloths.

Table 5.12: Percent Distribution of RDW Reporting Any Birth Preparedness According to Background Characteristics Any BPP Background Characteristics N % Ecological Zone * Mountain 733 86.5 Hill 1,216 86.5 Terai 1,301 92.4 Province * Province 1 485 91.9 Province 2 473 89.6 Province 3 482 91.3 Province 4 441 89.3 Province 5 452 85.6 Province 6 487 92.2 Province 7 430 81.6 Age * 15-19 510 85.4 20-24 1,366 89.3 25-29 851 90.6 30-34 344 88.4 35-49 179 86.5 Literacy Status * Literate 2,722 90.4 Illiterate 528 81.1 Education Level * No schooling 560 81.5 Primary 393 85.8 Some secondary 1,253 89.8 SLC and above 1,044 93.2 Ethnicity * Brahmin/Chhetri 1,204 89.7 Dalit 565 86.0 Janajaties 1,106 88.4 Other Terai Caste and Religious Minorities 375 91.2 Wealth Quintile * Lowest 594 81.3 Second 637 86.9 Third 656 90.0 Fourth 674 92.2 Highest 689 93.5 Total1 3,250 88.8 95% Confidence Interval (87.3-90.1) *Significant at <0.05 level ns= not significant 1Total includes those RDW who reported at lease one birth prepardness

27 5.8 CHX Knowledge and Receipt

Table 5.13: Percent Distribution of RDW Who Received CHX During Pregnancy According to Background Characteristics Received CHX During Pregnancy (N=3,661) Background Characteristics n % Ecological Zone * Mountain 136 16 Hill 333 24 Terai 246 17 Province * Province 1 111 21 Province 2 55 10 Province 3 83 16 Province 4 39 8 Province 5 178 34 Province 6 131 25 Province 7 118 22 Age ns 15-19 107 18 20-24 303 20 25-29 195 21 30-34 76 20 35-49 34 16 Literacy Status * Literate 638 21 Illiterate 77 12 Education Level * No schooling 77 11 Primary 85 19 Some secondary 286 20 SLC and above 267 24 Ethnicity * Brahmin/Chhetri 291 22 Dalit 131 20 Janajaties 250 20 Other Terai Caste and Religious Minorities 43 10 Wealth Quintile * Lowest 109 15 Second 140 19 Third 152 21 Fourth 171 23 Highest 143 19 Total 715 20 95% Confidence Interval (17-22) *Significant at <0.05 level ns= not significant

Table 5.14: Percent Distribution of the Source of CHX Receipt During Pregnancy Source of CHX n % Health facility 253 35 FCHV 446 62 Bought (separately or as part of a clean home delivery kit) 14 2 Total1 713 1Total includes those RDW who have received CHX during pregnancy.

Table 5.15: Percent Distribution of Source of CHX Receipt During Pregnancy Month of Pregnancy N % 3 3 0 4 9 1 5 12 2 6 18 3 7 34 5 8 342 48 9 295 41 Total1 713 1Total includes those RDW who have received CHX during pregnancy.

Table 5.16: Reasons Given for Not Obtaining CHX During Last Pregnancy by Recently Delivered Women Reason for Non-Receipt# N % Not aware of CHX 1,435 49 Out of stock with FCHV 171 6 No contact with FCHV 131 4 Health worker did not give woman CHX 1,428 48 CHX not needed 94 3 Other 168 6 Total1 #Multiple responses. Responses were not prompted. 1Total includes only those RDW who did not receive CHX during pregnancy (N=2946).

Table 5.17: Percent Distribution of Cited Purpose of Using and How to Use CHX Reported by RDW Knowledge on CHX n % Reasons for Using CHX# To prevent infection of umbilical cord 691 96.6 To reduce risk of death 152 21.3 Others 17 2.4 Don't know 14 2.0 Types of Advices Received# Wash hand with soap and water before applying CHX lotion 283 39.6 Apply immediately after cutting cord 566 79.2 Apply whole tube 306 42.8 Massage CHX in to cord 80 11.2 Apply CHX on stump and surrounding 489 68.4 After applying CHX keep stump untouched by clothes 76 10.6 Do not apply anything else to the cord and keep it clean and dry 125 17.5 Others 7 1.0 Don't know 7 1.0 Total1 715 #Multiple response. Responses were not prompted. 1Total includes those RDW who have received CHX.

29 CHAPTER 6: DELIVERY CARE AND COVERAGE OF MISOPROSTOL OR MATRI SURAKSHYA CHAKKI (MSC)

Proper planning and precautions during delivery are crucial to preventing the mother and the newborn from contracting infections and reducing the risk of complications that can result in serious illness or even death. Nepal is promoting safe motherhood through initiatives, such as providing free delivery care and transportation schemes to women delivering in a health facility (Family Health Division, 2002). The maternity incentive scheme was introduced by the government in 2005 to encourage women to use health facilities for delivery care and improve access to maternity care services (Ministry of Health, 2015). The Nepal government widely encourages delivery under the supervision of a health professional and emphasizes the importance of a clean and safe environment/room for delivery. Given this background, the survey team collected information on the knowledge and practices associated with delivery and the post-delivery period among women in the study districts.

6.1 Assistance During Delivery

Table 6.1: Percent Distribution of Persons Providing Assistance During Delivery and Persons Present Outside the Room During Delivery Reported by RDW Assistance During Delivery N % Persons Assisted During Delivery Doctor 1,288 35.2 Staff Nurse/ANM 2,636 37.6 HA/AHW/CMA 295 3.1 FCHV 141 2.5 Traditional birth attendant 140 3.0

Relatives/Friends 784 15.9 Others 40 0.6 Nobody 74 2.0 Don't know 1 0.0 Missing 1 0.0 Total 3,661 Persons Present Outside Labor Room# Traditional birth attendan 21 0.6 FCHV 126 3.4 Friends/Neighbors 548 15.0 Mother-in-law 1,354 37.0 Father-in-law 581 15.9 Husband 2,194 59.9 Mother 646 17.6 Father 207 5.7 Other relatives 2,576 40.7 Others 1 0.0 Nobody 148 4.0 Missing 1 0.0 Total 3,661 #Multiple responses. Responses were not prompted.

Table 6.2: Percent Distribution of RDW Who Received Assistance From SBA1 During Delivery By Background Characteristics Attended by SBA During Background Characteristics Delivery (N=3,661) N % Ecological Zone * Mountain 568 67.1 Hill 1,012 72.0 Terai 1,086 77.1 Province * Province 1 354 67.0 Province 2 302 57.2 Province 3 417 79.0 Province 4 394 79.8 Province 5 408 77.3 Province 6 342 64.8 Province 7 449 85.2 Age * 15-19 441 73.9 20-24 1133 74.1 25-29 700 74.5 30-34 273 70.2 35-49 119 57.5 Literacy status * Literate 2,329 77.4 Illiterate 337 51.8 Education level * No schooling 367 53.4 Primary 281 61.4 Some secondary 1,028 73.6 SLC and above 990 88.4 Ethnicity * Brahmin/Chhetri 1,092 81.4 Dalit 455 69.3 Janajaties 856 68.4 Other Terai Caste and Religious Minorities 263 64.0 Wealth Quintile * Lowest 404 55.3 Second 438 59.8 Third 531 72.8 Fourth 610 83.4 Highest 683 92.7 Total 2,666 72.8 95% Confidence Interval (70.4-75.1) *Significant at <0.05 level ns= not significant 1SBA includes Doctor, Staff Nurse, and ANM.

31 6.2 Place of Delivery

Table 6.3: Percent Distribution of RDW by Place of Delivery According to Background Characteristics

Types of Facility (N=2,696) Delivered in a Health Non- Background Characteristics Facility Government Government Private n % Sector Sector Sector Other Ecological Zone * * * * * Mountain 575 67.9 55.5 0.0 12.0 1.7 Hill 1,035 73.6 62.7 0.4 9.5 3.1 Terai 1,086 77.1 60.4 0.1 15.1 2.1 Province * * * * * Province 1 369 69.9 47.5 0.0 21.6 2.1 Province 2 300 56.8 39.4 0.0 14.2 3.2 Province 3 426 80.7 64.2 1.1 14.2 3.0 Province 4 393 79.6 66.8 0.2 12.3 1.0 Province 5 396 75.0 56.1 0.0 18.8 1.5 Province 6 358 67.8 64.4 0.0 2.5 3.4 Province 7 454 86.1 83.1 0.0 2.3 2.5 Age * * * * * 15-19 446 74.7 62.0 0.2 10.9 2.5 20-24 1,148 75.1 62.0 0.2 11.9 2.5 25-29 705 75.1 61.3 0.2 12.8 1.4 30-34 274 70.4 54.8 0.3 14.7 2.9 35-49 123 59.4 45.9 0.0 12.1 4.8 Literacy Status * * * * * Literate 2,343 77.8 62.7 0.2 13.9 2.3 Illiterate 353 54.2 48.5 0.2 4.8 3.1 Education Level * * * * * No schooling 377 54.9 49.1 0.0 5.4 3.2 Primary 290 63.3 54.4 0.7 6.8 2.7 Some secondary 1,032 73.9 59.7 0.1 13.1 2.3 SLC and above 997 89.0 69.8 0.2 17.7 2.0 Ethnicity * * * * * Brahmin/Chhetri 1,100 82.0 70.0 0.1 11.4 1.9 Dalit 458 69.7 61.6 0.2 7.5 2.3 Janajaties 877 70.1 53.7 0.3 15.0 2.6 Other Terai Caste and Religious Minorities 261 63.5 45.3 0.0 14.4 3.9 Wealth Quintile * * * * * Lowest 420 57.5 54.2 0.3 2.3 3.4 Second 457 62.3 54.7 0.3 5.9 3.7 Third 528 72.4 60.9 0.1 10.6 1.8 Fourth 610 83.4 65.9 0.0 17.4 0.8 Highest 681 92.4 65.0 0.3 25.1 2.3 Total 2,696 73.6 60.1 0.2 12.3 2.4 95% Confidence Interval (71.1-76.0) (57.7-62.5) (0.1-0.6) (10.9-13.8) (1.5-2.5) *Significant at <0.05 level ns= not significant

32 6.3 Access to Services during Delivery

Table 6.4: Percent Distribution of RDW Who Received an Injection of Oxytocin Immediately After Delivery and Who Had a Caesarian Section for Delivery Among Those Delivered in a Health Facility According to Background Characteristics Received an Injection of Oxytocin After Delivery Delivery by Caesarian Background Characteristics (N=2,696)1 Section (N=2,696)1 n % n % Ecological Zone * * Mountain 477 83.0 81 14.1 Hill 750 72.5 104 10.0 Terai 926 85.3 211 19.4 Province * * Province 1 309 83.7 95 25.7 Province 2 288 96.0 52 17.3 Province 3 355 83.3 81 19.0 Province 4 315 80.2 68 17.3 Province 5 322 81.3 50 12.6 Province 6 253 70.7 22 6.1 Province 7 311 68.5 28 6.2 Age ns * 15-19 362 81.2 37 8.3 20-24 906 78.9 149 13.0 25-29 575 81.6 120 17.0 30-34 209 76.3 63 23.0 35-49 101 82.1 27 22.0 Literacy Status ns * Literate 1,867 79.7 365 15.6 Illiterate 286 81.0 31 8.8 Education Level ns * No schooling 301 79.8 44 11.7 Primary 237 81.7 26 9.0 Some secondary 802 77.7 131 12.7 SLC and above 813 81.5 195 19.6 Ethnicity * * Brahmin/Chhetri 844 76.7 149 13.5 Dalit 352 76.9 53 11.6 Janajaties 709 80.8 155 17.7 Other Terai Caste and Religious Minorities 248 95.0 39 14.9 Wealth Quintile * * Lowest 321 76.4 29 6.9 Second 348 76.1 42 9.2 Third 418 79.2 52 9.8 Fourth 491 80.5 95 15.6 Highest 575 84.4 178 26.1 Total 2,153 79.9 396 14.7 95% Confidence Interval (77.8-81.8) (13.3-16.2) *Significant at <0.05 level ns= not significant 1Total includes those RDW who delivered in a health facility.

Table 6.5: Percent Distribution of RDW Who Paid Cash to the Health Facility Among Those Delivered in a Health Facility According to Background Characteristics Paid Cash to the Health Facility Background Characteristics (N=2,696)1 n % Ecological Zone * Mountain 120 20.9 Hill 156 15.1 Terai 320 29.5 Province * Province 1 102 27.6 Province 2 114 38.0 Province 3 166 39.0 Province 4 79 20.1 Province 5 108 27.3 Province 6 16 4.5 Province 7 11 2.4 Age * 15-19 86 19.3 20-24 243 21.2 25-29 160 22.7 30-34 81 29.6 35-49 26 21.1 Literacy Status ns Literate 533 22.7 Illiterate 63 17.8 Education Level * No schooling 69 18.3 Primary 48 16.6 Some secondary 229 22.2 SLC and above 250 25.1 Ethnicity * Brahmin/Chhetri 196 17.7 Dalit 69 15.1 Janajaties 241 27.5 Other Terai Caste and Religious Minorities 91 34.9 Wealth Quintile * Lowest 34 8.1 Second 60 13.1 Third 92 17.4 Fourth 158 25.9 Highest 252 37.0 Total 596 22.1 95% Confidence Interval (20.2-24.1) *Significant at <0.05 level ns= not significant 1Total includes those RDW who delivered in a health facility.

34 6.4 Experienced Danger Signs During and After Delivery of the Last Child

Table 6.6: Percent Distribution of RDW Who Encountered a Danger Sign During Delivery and Actions Taken for the Problems Encountered

n % Any Danger Sign Encountered During Delivery Yes 1,432 39.1 No 2,229 60.9 Total 3,661 100.0 Types of Danger Sign Encountered# Labor longer than 8 hours 1,229 85.8 Appearance of baby's hand/leg/placenta first 27 1.9 Excessive bleeding before or after delivery 431 30.1 Convulsion 190 13.3 Total1 1,432 Place of Treatment to Solve the Problem* Nowhere 217 15.2 Government Hospital 554 38.7 Primary Health Care Centre 71 5.0 Urban Health Clinic 1 0.1 Health post/sub-health post 399 27.9 Community Health Unit 3 0.2 Outreach Clinic 1 0.1 Pvt. Hospital/Clinic/Nursing Home/NGOs 138 9.6 Medical shop/Pharmacy 2 0.1 FCHV 10 0.7 Traditional birth attendant 8 0.6 Traditional healer 4 0.3 Others 22 1.5 Missing 2 0.1 Total1 1,432 100.0 #Multiple responses. Responses were prompted. *Multiple responses. Responses were not prompted. 1Total includes those RDW who have encountered a danger sign during last pregnancy.

Table 6.7: Percent Distribution of RDW Who Were Referred After Encountering a Danger Sign During Delivery and the Place They Went After Receiving the Referral; and the Reasons for Not Going to the Referred Place Among Those Who Didn't Go to the Referred Place

N % Referred During Delivery Went to referred facility for treatment 158 84.0 Did not go to referral facility for treatment 246 16.0 Total 404 100.0 Referred Place Attended Government hospital 111 70.3 Primary Health Care Centre 1 0.6 Health post/Sub-health post 2 1.3 Private hospital/nursing home 44 27.8 Total1 158 100.0 Reasons for Not Going to the Referred Place# Don't know where to go 5 2.0 Didn't have money 22 8.9 Didn't have time 39 15.9 No-one to accompany 30 12.2 Don't have faith in health facility 5 2.0 Health facility closed 11 4.5 No health worker in health facility 2 0.8 Too far to go 124 50.4 Not necessary 28 11.4 Others 56 22.8 Total2 246 100.0 #Multiple responses. Responses were not prompted. 1 Includes only those who were referred and went to the referral facility. 2 Includes only those who were referred and did not attend the referral facility.

35 6.5 Awareness of Misoprostol “Matri Suraksha Chakki”

Table 6.8: Percent Distribution of RDW’s Knowledge on Purpose and Timing of Taking MSC, and the Conditions to Avoid Matri Suraksha Chakki (MSC) Knowledge About MSC N % Heard of MSC Yes 130 3.6 No 3,531 96.4 Total 3,661 100.0 Purpose of Taking MSC#,1 Prevention of PPH 105 89.0 Prevent from the risk of death 25 21.2 Contraction of uterus 30 25.4 Delivery of the placenta 10 8.5 Others 1 0.8 Don't know 12 9.2 Right Time of Taking MSC#,1 Immediately after the delivery of baby and placenta 56 48.7 After delivery of baby but before delivery of the placenta 54 46.9 Others 5 4.4 No. of Tablets to be Taken1 One 6 4.65 Two 6 4.65 Three 96 73.8 Four 2 1.5 Do not know 20 15.4 Conditions to Avoid MSC#,1 During pregnancy 105 95.5 If the placenta comes out before taking MSC 6 5.50 During labor but before delivery 39 35.5 Total1 130 # Multiple responses. Responses were not prompted. 1The total includes only those RDW who had heard of MSC.

Table 6.9: Percent Distribution of Recently Delivered Women (RDW) Who Had Received Matri Surakshya Chakki (MSC), and Among Those Who Had Received It, the Person Who Gave Them the MSC, Number of MSC Given and the Mean Month of Pregnancy When MSC Was Received Background Characteristics n % MSC Received Yes 57 43.8 No 73 56.2 Total1 130 100.0 Persons Who Gave MSC FCHV 41 71.9 Health Workers 15 26.3 Others 1 1.8 No. of MSC Received Three or more tablets (Required number) 53 93.0 Others 4 7.1 Total2 57 Mean month of pregnancy when received MSC 8.14 1The total includes those RDW who had heard of MSC. 2The total includes those RDW who had received MSC.

Table 6.10: Percent Distribution of Reasons Given by RDW of Not Receiving Matri Surakshya Chakki (MSC ) Reasons for Not Receiving MSC# n % Not aware of MSC 6 8.5 FCHV did not have the stock 14 19.7 Was away from home 4 5.6 No contact/ don't know/didn't go to check with FCHV 2 2.8 Heath facility was out of stock 3 4.2 Health facility didn’t give 39 54.9 Don't know the importance of MSC 9 12.7 Others 11 15.5 Total1 73 # Multiple responses. Responses were not prompted. 1Total includes those RDW who had not received MSC.

6.6 Knowledge Regarding Precautions when Taking MSC and its Side Effects

Table 6.11: Percent Distribution of RDW by Their Knowledge on Precautions to be Taken With MSC as Communicated by the FCHV or Health Worker Precautions About MSC as Told by the FCHV# n % MSC should not be taken during pregnancy 72 58.5 Taking MSC in pregnancy is dangerous 38 30.9 Did not say anything 43 35.0 Didn't meet the FCHV or health worker before delivery 2 1.6 Others1 5 4.1 Don't know 7 5.3 Total2 130 #Multiple responses. Responses were not prompted. 1Others includes after one hour of delivery, when delivered in health facility. 2Total includes those RDW who had heard of MSC.

Table 6.12: Percent Distribution of Side Effects of Tablets as Reported by RDW# Side Effect/Problem of Taking MSC# n % Shivering 11 15.1 Nausea 55 75.3 Headache 36 49.3 Fever 26 35.6 Diarrhea 7 9.6 Nothing will happen 3 4.1 Other 12 16.4 Don’t know 8 6.15 Total1 130 #Multiple responses. Responses were not prompted. 1Total includes those RDW who had heard of MSC (N=130).

7.3 Coverage of Matri Surakshya Chakki

Table 6.13: Percent Distribution of the Number and Timing of Matri Surakshya Chakki (MSC) Intake as Reported by RDW Among Home Deliveries Quantity and Timing of MSC Taken n % Did you take MSC Yes 10 76.9 No 3 23.1 Total1 13 100.0 No. of tablets taken All three tablets 10 100.0 Timing of taking MSC After delivery of baby but before delivery of placenta 5 50.0 Immediately after delivery of baby and placenta 5 50.0 Total2 10 1Total includes those RDW who received MSC tablets and had home deliveries. 2Total includes those RDW who took MSC tablets.

38 CHAPTER 7: POSTPARTUM CARE

In developing countries like Nepal, postpartum hemorrhage (PPH) is a major cause of maternal death and, arguably, the most preventable. It is therefore critical to ensure the receipt of proper postpartum care (including checkups, treatments, and familial care), especially for the six weeks immediately following delivery. The postpartum checkup diagnoses the improper placement of the uterus, anemia, contracted infections, and other danger signs that have consequences on a mother’s health and life, therefore enabling timely management of diagnosed complications. For the timely diagnosis and treatment of postpartum complications, MOHP has been advocating for at least three postpartum checkups, whereby the first checkup should take place within the first 24 hours of the delivery, the second on the third day, and the third on the seventh day after delivery. This chapter presents information on the utilization of postpartum services by the RDW.

7.1 Female Community Health Volunter Home Visits During the Postpartum Period

Table 7.1: Percent Distribution of Timing of First and Further Home Visits by FCHV Within Six Weeks Following the Birth of Their Last Child as Reported by RDW N % Home Visit by a FCHV Yes 1,261 34.4 No 2,400 65.6 Total 3,661 100.0 Number of Visits by a FCHV At least one visit 292 23.2 At least two visits 642 50.9 At least three visits 327 25.9 Total1 1,261 Timing of First Visit Same day of delivery 394 31.3 2nd to 3rd day after delivery 403 32.0 After 3rd day after delivery 462 36.7 Mean days for first visit after birth 5.2 Total1 1,259 100.0 Timing of Second Visit Within 2 days of delivery 157 24.6 3rd day after delivery 79 12.4 After 3rd day after delivery 403 63.1 Mean days for second visit after birth 8.09 Total2 639 100.0 Timing of Third Visit Within 6 days of delivery 125 38.3 7th day after delivery 37 11.3 After 7th day after delivery 164 50.3 Mean days of third visit after birth 10.0 Total3 326 100.0 1Total includes only those RDW who were visited by FCHV after delivery. 2Total includes only those RDW who had received at least two visits. 3Total includes only those RDW who had received at least three visits.

39 7.2 Postpartum Checkups

Table 7.2: Percent Distribution of the Number of Postpartum Checkups Within Six Weeks of Delivery by Health Workers or FCHV as Reported by RDW Home and Other Institutional Delivery Number of Times of PP Checkups Delivery n % n % 1 time 1,197 44.8 236 23.9 2 times 729 27.3 51 5.2 3 times 217 8.1 10 1.0 4 times or more 498 18.6 6 0.6 No checkups 33 1.2 684 69.3 Mean no. times 2.5 0.4 Total 2,674 100.0 987 100.0

Table 7.3: Percent Distribution of Postpartum Checkups Within Six Weeks of Delivery by Health Workers as Reported by RDW (by background characteristics) Home and Other Institutional Delivery Delivery Location (N=2,674)1 Background Characteristics (N=987)2 n % n % Ecological Zone ns * Mountain 569 99.5 79 28.7 Hill 1,006 98.4 93 24.2 Terai 1,066 98.7 131 39.9 Province * * Province 1 364 99.7 63 38.7 Province 2 298 99.7 90 39.3 Province 3 416 99.0 22 20.4 Province 4 381 97.2 33 32.4 Province 5 394 99.7 34 25.6 Province 6 350 99.2 42 24.0 Province 7 438 97.3 19 24.7 Age ns ns 15-19 431 98.2 49 31.0 20-24 1,125 98.7 132 33.9 25-29 699 99.4 69 29.2 30-34 269 98.9 26 22.2 35-49 117 97.5 27 31.0 Literacy Status ns * Literate 2,295 98.8 231 33.7 Illiterate 346 98.9 72 23.9 Education Level ns * No schooling 370 98.7 76 24.4 Primary 282 98.6 48 27.9 Some secondary 1,010 98.7 122 32.7 SLC and above 979 98.9 57 43.8 Ethnicity ns * Brahmin/Chhetri 1,079 98.6 83 33.5 Dalit 447 98.0 48 23.9 Janajaties 856 99.0 110 28.5 Other Terai Caste and Religious Minorities 259 100.0 62 40.8 Wealth Quintile ns * Lowest 411 99.0 70 22.2 Second 438 97.8 86 30.2 Third 520 99.0 67 32.8 Fourth 601 98.7 46 37.7 Highest 671 99.1 34 56.7 Total 2,641 98.8 303 30.7 95% Confidence Interval (98.0-99.3) (26.8-34.9) *Significant at <0.05 level ns= not significant 1Total includes only those RDW who had institutional delivery.

40 2Total includes only those RDW who had home delivery.

Table 7.4: Percent Distribution of the Timing of the First Postpartum Check-up Within Six Weeks of Delivery and the Type of Health Worker Who Provided the Check-up by the Place of Delivery as Reported by RDW Home and Other Delivery Institutional Delivery Location n % n % Timing of First Check-up Same day of delivery 2,612 98.9 204 67.3 1- 7 days 27 1.0 44 14.5 After a week 2 0.1 55 18.2 Mean no. of days 0.03 4.45 Total1 2,641 98.7 303 30.6 Type of HW in 1st Check-up# Doctor 1,095 41.5 23 7.6 Nurse/ANM 1,581 59.9 144 47.5 HA/AHW/CMA 87 3.3 132 43.6 FCHV 1 0.0 4 1.3 Others2 0 0.0 7 2.3 Total1 2,641 303 # Multiple responses. Responses were not prompted. 1Total includes those RDW who went for PP checkups. 2Others includes medical shopkeeper, uncertified doctors and TBA.

\ Table 7.5: Percent Distribution of the Timing of the Second Postpartum Check-up and the Type of Health Worker Who Provided the Check-up Reported by RDW Institutional Delivery Home Delivery

n % n % Timing of Second Postpartum Check-up 1-7 days 1,364 94.5 37 55.2 After a week 79 5.5 30 44.8 Mean no. of days 2.5 10.7 Type of HW in Second Check-up# Doctor 769 53.3 13 19.4 Nurse/ANM 719 49.8 38 56.7 HA/AHW/ CMA 48 3.3 19 28.4 FCHV 1 0.1 1 1.5 TBA 1 0.1 - - Total1 1,443 67 # Multiple responses. Responses were not prompted. 1Total includes only those RDW who had second PP checkups.

Table 7.6: Percent Distribution of Places Visited for Postpartum Checkups Within Six Weeks of Delivery as Reported by RDW Places Visited for PP Checkups# n % Government Hospital 1,390 47.2 PHCC 115 3.9 Urban health clinic 4 0.1 Health post/sub-health post 897 30.5 Community health unit 12 0.4 PHC/OR clinic 22 0.7 Private Hospital/Clinic/Nursing home 508 17.3 Own home 181 6.2 Others home 5 0.2 Hospital in India 13 0.4 Other 2 0.1 Total1 2,943 #Multiple responses. Responses were not prompted. 1Total includes only those RDW who had PP checkups.

Table 7.7: Percent Distribution of the Types of Postpartum Checkup Service Components Received as Reported by RDW Postpartum Services# n % Abdomen examination 2,445 83.1 Perineum examination 1,685 57.2 Inquiring excessive bleeding/severe abdominal pain 2,494 84.7 Counseled about Family Planning 1,772 60.2 Counseled about exclusive breastfeeding up to 6 months 2,483 84.3 Counseled about immunization 2,464 83.7 Counseled on skin to skin care 2,275 77.3 Counseled on thermal care 2,490 84.6 Counseled on cord care 1,907 64.8 Total1 2,943 All of the above 765 26.0 #Multiple responses. Responses were prompted. 1Total includes only those RDW who went for PP checkups.

42 7.3 Intake of Iron Folic Acid Tablets and Vitamin A Capsule in the Postpartum Period

Table 7.8: Percent Distribution of RDW According to Background Characteristics Who Took Iron Folic Acid Tablets and Vitamin A Capsule During Their Post-Partum Period Took At Least 42 Recommended Iron Took Vitamin A Capsule Background Characteristics Took Iron Folic Acid Folic Acid Tablets in Post-Partum Period Tablets (N=3,661) (N=2,482)1 (N=3,661) n % n % n % Ecological Zone * * * Mountain 597 70.5 280 46.9 474 56.0 Hill 992 70.6 493 49.7 832 59.2 Terai 893 63.4 380 42.6 647 46.0 Province * * * Province 1 354 67.0 151 42.7 269 50.9 Province 2 193 36.6 65 33.7 195 36.9 Province 3 386 73.1 173 44.8 240 45.5 Province 4 374 75.7 198 52.9 245 49.6 Province 5 407 77.1 193 47.4 299 56.6 Province 6 388 73.5 186 47.9 324 61.4 Province 7 380 72.1 187 49.2 381 72.3 Age * ns * 15-19 367 61.5 166 45.2 285 47.7 20-24 1,061 69.4 488 46.0 812 53.1 25-29 659 70.2 312 47.3 530 56.4 30-34 267 68.6 120 44.9 215 55.3 35-49 128 61.8 67 52.3 111 53.6 Literacy Status * * * Literate 2,181 72.5 1,039 47.6 1,657 55.0 Illiterate 301 46.2 114 37.9 296 45.5 Education Level * * * No schooling 325 47.3 134 41.2 322 46.9 Primary 282 61.6 117 41.5 232 50.7 Some secondary 954 68.3 453 47.5 734 52.6 SLC and above 921 82.2 449 48.8 665 59.4 Ethnicity * * * Brahmin/Chhetri 1,052 78.4 522 49.6 822 61.3 Dalit 422 64.2 179 42.4 341 51.9 Janajaties 848 67.8 395 46.6 643 51.4 Other Terai Caste and Religious Minorities 160 38.9 57 35.6 147 35.8 Wealth Quintile * ns ns Lowest 445 60.9 202 45.4 417 57.0 Second 473 64.5 207 43.8 388 52.9 Third 474 65.0 237 50.0 382 52.4 Fourth 503 68.8 245 48.7 383 52.4 Highest 587 79.6 262 44.6 383 52.0 Total 2,482 67.8 1,153 46.5 1,953 53.3 95% Confidence Interval (65.7-69.9) (44.2-48.7) (51.0-55.6) *Significant at <0.05 level ns= not significant 1Total includes only those RDW who took iron folic acid tablets during postpartum period.

43 7.4 Awareness of Danger Signs During the Postpartum Period (PP)

Table 7.9: Percent Distribution of Reported Postpartum Danger Signs and Where to Seek Care by RDW Danger Signs During PP Period n % Cited Symptoms# Fever 1,600 45.1 Pain in the lower abdomen or smell vaginal discharge 1,946 54.9 Excessive bleeding 3,061 86.3 Severe headache 890 25.1 Convulsion 482 13.6 Discharge from the wounds 47 1.3 Dizziness or weakness 104 2.9 Problems in uterus or uterine prolapsed 107 3.0 Swelling of hand, feet or body 58 1.6 Other 86 2.4 Know at least three danger signs out of five danger signs1 3,328 90.9 Know more than three danger signs out of five danger signs1 198 5.4 None 135 3.7 Identified HFs to Go to if Danger Signs Persist# Government Hospital 2,791 76.3 Primary health care center 315 8.6 Health post/sub health post 2,588 70.7 Urban health clinic 46 1.3 PHC/OR clinics 135 3.7 Private hospital/nursing home 1,445 39.5 Community health unit 24 0.7 Medical shop/pharmacy 288 7.9 FCHV 233 6.4 Traditional birth attendant 4 0.1 Traditional healers 62 1.7 Other 6 0.2 Total 3,661 #Multiple responses. Responses were not prompted. 1The five danger sign includes: Fever, pain in lower abdomen or smelling vaginal discharge, excessive bleeding, severe headache and convulsion.

Table 7.10: Percent Distribution of RDW by Postpartum Danger Signs Informed by Health Workers Types of Counseling Received# N % High fever 1,712 46.8 Severe lower abdominal pain 2,172 59.3 Foul smelling discharge 1,811 49.5 Excessive bleeding 2,415 66.0 Severe headache 1,704 46.5 Convulsions 1,396 38.1 The place to go for health services for postpartum care 2,031 55.5 Total 3,661 #Multiple responses. Responses were prompted.

44 CHAPTER 8: IMMEDIATE NEWBORN CARE IN HOME DELIVERIES, AND APPLICATION OF SUBSTANCES TO THE CORD

8.1 Immediate Newborn Care Among Home Deliveries

Table 8.1: Percent Distribution of Immediate Newborn Care Practices Among Home Delivery as Reported by RDW Immediate Newborn Care n % The Person that helped during delivery washed hand before handling the newborn Yes 587 61.3 No 370 38.7 When was the baby wiped off/dried Before the placenta was delivered 435 45.5 After the placenta was delivered 504 52.7 Didn't dried 8 0.8 Don't know 10 1.0 Types of cloths used to wipe the baby Clean and dried 883 94.0 Dried but dirty 46 4.9 We and dirty 2 0.2 Don't know 8 0.9 When was the baby wrapped in cloth and put on mother's body Before the placenta was delivered 179 18.7 After the placenta was delivered 586 61.2 Didn't wrap/Didn't put on mother's body 190 19.9 Don't know 2 0.2 Types of cloths used to wrap the baby Clean and dried 754 98.6 Dried but dirty 10 1.3 Don't know 1 0.1 Where was the baby placed before the placenta was delivered On the floor 461 48.2 On the cot 73 7.6 Besides or on the mother's body 107 11.2 With someone else 285 29.8 Others 28 2.9 Don't know 3 0.3 Time when cord was cut (N=987) <=5 minutes 371 37.6 6-15 minutes 350 35.5 16-60 minutes 188 19.0 More than 1 hour 38 3.9 Don't know 40 4.1 Median minutes 8.9 Total1 957 100.0 1Total includes only those RDW who had live birth in home delivery.

45 8.2 Umbilical Cord Cutting Practices

Table 8.2: Percent Distribution of the Type of Instrument Used to Cut and Tie the Umbilical Cord Among Home Deliveries as Reported by RDW Descriptions of Instruments n % Instruments used to cut the umbilical cord of the newborn CHDK 134 14.0 New Blade 640 66.9 Used Blade 26 2.7 Knife 19 2.0 Sickle (Hasiya) 85 8.9 Khukuri 8 0.8 Scissor 27 2.8 Others1 13 1.4 Do not know 5 0.5 Total2 957 100.0 Sterilization of instruments used3 Instrument was boiled 21 11.8 Instrument was not boiled 149 83.7 Do not know/Do not remember 8 4.5 Total4 178 100.0 Instruments used to tie the umbilical cord of newborn among those who had not used CHDK Nothing 16 1.9 New string/thread 703 85.4 Boiled used string/thread 6 0.7 Not boiled, used string/thread 87 10.6 Others5 8 1.0 Do not know 3 0.4 Total6 823 100.0 1Others includes used blade, knife, sickle (hasiya, chulesi), khukuri, scissors 2Total includes only those RDW who had a live birth in home delivery. 3Sterilization of the instruments was analyzed only among those who have used instruments other than “new or boiled blade” to cut the umbilical cord. 4Total includes only those RDW who did not use CHDK or new/boiled blade. 5Others includes clip, tongue, rubber. 6Total includes only those RDW who had home delivery and did not use CHDK.

Table 8.3: Percent Distribution of the Type of Surface Used While Cutting the Cord Among Those RDW Who Had Not Used CHDK in Home Deliveries Types of Surface n % Nothing 267 32.4 Plastic disc 15 1.8 Metal coin/vessel 183 22.2 Wood/wooden vessel/stick 258 31.3 Others1 38 4.6 Do not know 62 7.5 Total2 823 100.0 1Other include a bamboo spatula, an iron rod, and a finger nail. 2Total includes only those RDW who had home delivery and did not use CHDK.

46 8.3 Application of Substances to the Umbilical Cord (all live births)

Table 8.4: Percent Distribution of the Substance Used on the Cord Stump of the Newborn as Reported by RDW Types of Substance Applied# n % CHX 2,159 59.2 Oil 407 11.2 Others1 280 7.7 Nothing 995 27.3 Only CHX Applied to the Cord 2,103 58 Total2 3644 # Multiple responses. Responses were prompted. 1Others include animal dung, ghee, butter, ointment, powder, and milk. 2Total includes only those RDW who had live birth.

Table 8.5: Percent Distribution of RDW by CHX Application on Umbilical Cord of the Newborn by Background Characteristics of RDW CHX Applied to the Umbilical Background Characteristics Cord (N=3,644)1 n % Ecological Zone * Mountain 450 53.1 Hill 926 65.9 Terai 783 55.6 Province * Province 1 295 55.9 Province 2 206 39.0 Province 3 303 57.4 Province 4 273 55.3 Province 5 348 65.9 Province 6 342 64.8 Province 7 392 74.4 Age * 15-19 354 59.3 20-24 916 59.9 25-29 570 60.7 30-34 219 56.3 35-49 100 48.3 Literacy Status * Literate 1,898 63.1 Illiterate 261 40.1 Education Level * No schooling 272 39.6 Primary 224 48.9 Some secondary 864 61.9 SLC and above 799 71.3 Ethnicity * Brahmin/Chhetri 947 70.6 Dalit 382 58.1 Janajaties 663 53.0 Other Terai Caste and Religious Minorities 167 40.6 Wealth Quintile * Lowest 368 50.3 Second 405 55.3 Third 444 60.9 Fourth 454 62.1 Highest 488 66.2 Total 2,159 59.0 95% Confidence Interval (56.4-61.5) *Significant at <0.05 level ns= not significant

47 1Total includes only those RDW who had live birth. Table 8.6: Percent Distribution of Reasons Cited for Not Applying CHX Despite Receiving It During Pregnancy as Reported by RDW n % Reasons for not applying CHX despite receiving it# Delivered at a health facility but health staff did not apply 3 15.0 Thought it was not useful or necessary 1 5.0 Forgot to apply 5 25.0 Family members/others didn’t allow to use 3 15.0 Lost CHX 3 15.0 Others 6 30.0 Total1 20 # Multiple responses. Responses were not prompted. 1Total includes only those RDW who didn't apply the CHX to their newborn despite receiving it.

Table 8.7: Percent Distribution of Person Applying CHX on the Umbilical Cord Stump of the Newborn as Reported by RDW Person Who Applied the CHX n % Health Worker 1,885 87.3 FCHV 109 5.0 TBA 13 0.6 Family members 142 6.6 Others1 10 0.5 Total2 2,159 100.0 1Others include peon of HF and neighbor. 2Total includes only those RDW who had applied CHX to their new born.

Table 8.8: Percent Distribution of the Timing of Application of the CHX After the Cutting of the Umbilical Cord as Reported by RDW Time Period of CHX Application After the Cord Was Cut n % Within 2 hours 1,863 86.3 After 2 hours 30 1.4 Do not know 266 12.3 Average minutes 22.0 Total1 2,159 100.0 1Total includes only those RDW who had applied CHX to their new born.

Table 8.9: Percent Distribution of Different Aspects of CHX Application Among Home Deliveries as Reported by RDW Aspect of Application of CHX n % Body part of newborn where CHX was applied Stump only 10 3.3 Surrounding area only 6 2.0 Both in stump and surrounding area 280 92.1 Don’t know 8 2.6 Total1 304 100.0 Amount of CHX applied Whole content of the tube 246 80.9 Some content of the tube 47 15.5 Don’t know 11 3.6 Total1 304 100.0 Reasons for not applying the whole content CHX in the child’s umbilical cord# Tube lotion is more for one application 6 12.8 Thought more than one application was effective 16 34.0 Did not know that whole content of the tube must be applied at one time 17 36.2 Others 4 8.5 Don’t know 4 8.5 Total2 47 100.0 Times of CHX application Once 270 88.8 More than once 33 10.9 Don’t know 1 0.3 Mean no. of times of application 1.2 Total1 304 100.0 Contact of cord with clothes after applying CHX Kept the cord stump untouched for some time 261 85.9 The cord was not untouched 33 10.9 Don’t know 10 3.3 Total1 304 100.0 #Multiple responses. Responses were not prompted. 1Total includes only those RDW who delivered at home and who had applied CHX to their new born. 2Total includes only those RDW who delivered at home and who had not applied the whole content of CHX.

Table 8.10: Percent Distribution of RDW by Background Characteristics Among Home Deliveries Who Met Compliance of CHX Complied With Correct CHX Background Characteristics Application (N=321)1,2 N % Ecological Zone ns Mountain 48 62.3 Hill 92 60.1 Terai 60 65.9 Province ns Province 1 46 68.3 Province 2 39 67.2 Province 3 10 38.5 Province 4 14 58.3 Province 5 40 65.5 Province 6 38 63.9 Province 7 12 57.1 Age ns 15-19 27 49.1 20-24 83 63.8 25-29 53 67.9 30-34 25 61.0 35-49 12 63.2 Literacy Status ns Literate 160 63.5 Illiterate 40 58.0 Education Level ns No schooling 42 62.7 Primary 24 54.5 Some secondary 85 62.0 SLC and above 49 67.1 Ethnicity * Brahmin/Chhetri 74 72.5 Dalit 32 59.3 Janajaties 66 53.2 Other Terai Caste and Religious Minorities 28 68.3 Wealth Quintile ns Lowest 49 57.0 Second 55 58.5 Third 46 67.6 Fourth 31 68.9 Highest 19 67.9 Total 200 62.3 95% Confidence Interval (56.3-68.0) 1Total includes only those RDW who delivered at home and reported applying CHX 2 Compliance means RDW reported washing hand before applying CHX, applied CHX within two hours of delivery, applied CHX to both cord and stump, and left cord untouched for sometimes.

50 8.4 Problems with the Umbilical Cord (All Live Births)

Table 8.11: Percent Distribution of the Types of Problem Encountered in the Cord Stump, Action Taken Against the Problem, and the Timing of the Cord Stump Fall as Reported by RDW n % Problem with the Umbilical Cord1 540 14.8 Type of problem encountered# Infection on the cord stump 399 73.9 Delay in cord falling off 53 9.8 Bleeding from cord 182 33.7 Other 11 2.0 Total2 540 Actions taken for the problem# Nothing 26 4.8 Visited a health facility/health worker 225 41.7 Consulted a pharmacy 114 21.1 Home remedy 180 33.3 Other 20 3.7 Total2 540 Time of cord stump fall Within 5 days 663 19.6 6-10 days 1,825 53.9 More than 10 days 872 25.7 Do not know 27 0.8 Mean number of days 8.9 Total3 3,387 100.0 # Multiple responses. Responses were not prompted. 1Total includes all live births (N=3,644) 2The total includes only those RDW who had encounter problem to their newborn's umbilical cord. 3The total includes only those RDW whose child was above one month of age.

51 CHAPTER 9: NEWBORN CARE DURING THE FIRST MONTH

The MOHP has established a protocol for checkups of newborns by health workers, calling for at least three checkups: first within 24 hours of birth and second and third checkups on the third and seventh days, respectively. These checkups not only assess the status of the baby’s health and diagnose danger signs, but also provide important counseling on immunization, breast feeding, and other key issues.

9.1 Knowledge of Issues in Newborn Care

Table 9.1: Percent Distribution of RDW by Their Knowledge About Newborn Issues as Reported by RDW Type of Symptoms for Seeking Immediate Health Care# n % Poor suckling or not able to feed 1,656 45.2 Convulsions/Fits 138 3.8 Fast breathing 1,112 30.4 Severe chest in-drawing 325 8.9 Fever 3,360 91.8 Hypothermia 197 5.4 Difficult to wake/lethargic/unconscious 110 3.0 Redness of skin around the cord 301 8.2 Discharge from the cord 553 15.1 Nasal flaring 33 0.9 Grunting 136 3.7 Bulging fontanelle 12 0.3 Discharge from the eyes 179 4.9 Skin pustules 980 26.8 Cold/Cough 527 14.4 Jaundice 171 4.7 Diarrhea 402 11.0 Excessive vomiting/Nausea 82 2.2 Pneumonia 95 2.6 Unable to pass the stool or urine 89 2.4 Others1 123 3.4 Do not know 26 0.7 Total 3,661 #Multiple responses. Responses were not prompted. 1Others include swelling of abdomen and limbs, baby doesn't sleep well, cries a lot, weight loss, worm infestation.

52 9.2 Access to Neonatal Checkup Services

Table 9.2: Percent Distribution of Health Services Received by Newborn as Reported by RDW n % Newborn checked by a HW or FCHV within four weeks of birth Yes 2,965 87.5 No 422 12.5 Total1 3,387 100.0 Type of HW who did the checkups for newborn within four weeks of birth# Doctor 1,176 39.7 Nurse/ANM 2,116 71.4 HA/AHW/CMA 308 10.4 FCHV 255 8.6 Don't know/Don't remember 5 0.2 Total2 2,965 Newborn received BCG vaccine 3,276 96.7 Total1 3,387 100.0 #Multiple responses. Responses were not prompted. 1Total includes only those RDW who have live birth and the newborn above one month of age at the time of interview. 2Total includes only those RDW whose newborn were at least one month old at the time of interview and were check by HW of FCHV with in four weeks of birth.

Table 9.3: Percent Distribution of Newborn According to Number of Times Health Services Received by Health Worker or FCHV as Reported by RDW Health Worker FCHV n % n % No. of times health checkups was done in four weeks of birth Once 895 33.1 85 33.3 Twice 894 33.0 68 26.7 Thrice 341 12.6 38 14.9 Four or more times 575 21.3 64 25.1 Mean number of times 2.75 2.57 Total1 2,705 255 First checkups done on Same day of birth 2,506 92.6 165 64.7 Day after birth 21 0.8 16 6.3 After two days 178 6.6 74 29.0 Mean number of days 1.01 1.89 Total1 2,705 255 1Total includes only those RDW whose newborn were at least one month old at the time of interview and were check by HW of FCHV with in four weeks of birth.

9.3 Health Issues Encountered by Neonates and Treatment-Seeking Behaviors After Encountering Health Problems

Table 9.4: Percent Distribution of Types of Health Problems Faced by Newborns Within Eight Weeks of Birth as Reported by RDW Health Problems in Newborn n % Health problems in neonates during first 8 weeks No Problem 1,935 60.6 At least 1 or more problem 1,257 39.4 Total1 3,192 100.0 Type of problems faced# Fever 782 62.2 Feeding problem 138 11.0 Grunting 123 9.8 Fast breathing 192 15.3 Chest-in-drawing 99 7.9 Drowsy/Unconscious 43 3.4 Discharge from the umbilicus 296 23.5 Convulsions 40 3.2 Discharging eyes 60 4.8 Skin pustules 182 14.5 Redness around cord 208 16.5 Nasal flaring 50 4.0 Bulging fontanelle 34 2.7 Felt cold/hypothermia 30 2.4 Total2 1,257 #Multiple responses. Responses were prompted. 1The total includes only those RDW who have live birth and the newborn above two months of age. 2The total includes only those RDW who had encountered problem in their newborn with eight weeks of birth.

Table 9.5: Percent Distribution of Health Seeking Behavior Pertaining to Neonatal Health Issues as Reported by RDW Action Taken After the Neonate Had Reported a Health Problem# n % Government hospital 233 18.5 PHCC 27 2.1 Health post/Sub-health post 391 31.1 Private hospital/Clinic/Nursing home 322 25.6 Pharmacy 188 15.0 FCHV 21 1.7 Traditional healers 17 1.4 Urban health clinic 14 1.1 PHC/ORC 19 1.5 Treatment at home 125 9.9 Did not seek treatment 81 6.4 Others 14 1.1 Total1 1,257 #Multiple responses. Responses were not prompted. 1Total includes only those RDW who had encountered a problem in their newborn with eight weeks of birth.

54 9.4 Child’s Weight and Size at Birth

Table 9.6: Percent Distribution of Aspects of Weighing the Newborns as Reported by RDW Weight Monitoring n % RDW saying the child was weighed ever Yes 3,344 91.7 No 299 8.2 Don't know 4 0.1 Total1 3,647 100.0 Time when baby was first weighed Day of birth 2,792 83.5 1-2 days after birth 52 1.6 3 days after birth 25 0.7 After 3 days after birth 25 14.1 Don't know 2 0.1 Missing 1 0.0 Total2 3,344 100.0 Place where baby was weighed for the first time Government Hospital 1,398 41.8 PHCC 114 3.4 Urban health clinic 4 0.1 Health post/Sub-health post 977 29.1 Community health unit 15 0.4 PHC/Out reach 102 3.1 Private hospital/Clinic/Nursing home/NGOs 468 14.0 Pharmacy 10 0.3 Own home 217 6.5 Hospital of India 17 0.5 Others 21 0.6 Missing 1 0.0 Total2 3,344 100.0 Type of person weighing the baby for the first time Doctor 182 5.4 Nurse/ANM 2,766 82.7 HA/AHW/CMA 143 4.3 FCHV 219 6.5 Others5 33 1.0 Missing 1 0.0 Total2 3,344 100.0 Weight of the child as per mothers recall and/or birth card when measured

at birth <2.5 Kgs 246 8.8 >=2.5 Kgs 2543 91.1 Don't know 3 0.1 Total3 2,792 100.0 RDW’s perception of child’s size at birth Very large 133 3.6 Larger than average 617 16.9 Average 2,477 67.9 Smaller than average 308 8.4 Very small 89 2.4 Don't know 23 0.6 Total1 3,647 100.0 1Total includes only those RDW who had a live birth. 2Total includes only those RDW whose newborn was ever weighed. 3Total includes only those RDW whose newborn were weighted on the day of birth.

55 9.5 Care for Newborn Perceived to be Smaller Than Average

Table 9.7: Percent Distribution of Care Provided to Newborns Who Were Perceived as Small as Reported by RDW Type of Care Provided n % Newborn visited more times by HW/FCHV to check 140 35.3 Total1 397 Provided extra care to the child by RDW 342 86.1 Total1 397 Referred to HF 139 35.0 Total1 397 RDW Taking child to HF as advised2 79 56.8 Total2 139 1Total includes only those RDW who perceived their newborn as small. 2Total includes only those RDW whose newborn were revered to HF.

Table 9.8: Percent Distribution of Types of Advice Given by HW or FCHV Because the Child Was Small As Reported by RDW Advice Given by HW# n %

Frequent breast feeding 247 62.2 Keep baby warm 146 36.8 Keep baby close to mother's chest (skin to skin contact) 90 22.7 Newborn danger signs 11 2.8 Repeatedly weigh baby 59 14.9 Repeated visit to HF or HW 56 14.1 Others 18 4.5 No advice 128 32.2 Total1 397 #Multiple responses. Responses were not prompted. 1The total includes only those RDW who perceived their newborn as smaller than average.

Table 9.9: Percent Distribution of Types of Care Provided by RDW Because the Child Was Small Type of Care Provided# N % More frequent breastfeeding 329 96.2 Skin-to-skin contact 146 42.7 Breast milk fed by cup or spoon 28 8.2 Other 35 10.2 Total1 342 #Multiple responses. Responses were not prompted. 1The total includes only those RDW who provided extra care to their new born perceived as smaller than average.

56 CHAPTER 10: INFANT AND YOUNG CHILD FEEDING PRACTICES

Optimal infant feeding practices consist of exclusively breastfeeding up to the age of six months and then continued breastfeeding in addition to appropriate complementary feeding until the baby reaches at least two years of age. Feeding practices during infancy are critical for the growth, cognitive development, and health of a child, and are important for the early prevention of chronic degenerative diseases. Optimal infant and young child feeding (IYCF) practices include timely initiation of breastfeeding, exclusive breastfeeding, appropriate and timely introduction of complementary foods, meal frequency, and food diversity.

This chapter reviews the infant and young child feeding practices of the RDW, including the breastfeeding and feeding of solid/semi-solid foods, diversity of foods, and frequency of feeding the day preceeding the survey.

10.1 Initiation of Breastfeeding

Table 10.1: Percent Distribution of Breastfeeding Practices Among RDW Initiation of Breastfeeding n % Ever Breastfed the Child Yes 3,628 99.6 No 16 0.4 Total1 3,644 100.0 Initiation of Breastfeeding After Delivery Within one hour of birth 2,212 61.0 More than one hour (within one day after birth) 1,414 39.0 After one day of birth 2 0.05 Total2 3,628 100.0 Fed Colostrum to the child 3,586 98.8 Total2 3,628 Pre-lacteal feeding within 3 days of birth 526 14.5 Total2 3,628 1Includes children who were born alive. 2Total includes only those children who were ever breastfed.

Table 10.2: Percent Distribution of RDW by Background Characteristics Who Breastfed Their Last Child Within One Hour of Birth Breastfed Child Within One Background Characteristics Hour of Birth (N=3,628)1 n % Sex of Child ns Male 1,163 60.8 Female 1,049 61.1 Ecological Zone * Mountain 493 58.9 Hill 967 69.5 Terai 752 53.8 Province * Province 1 315 60.7 Province 2 232 43.9 Province 3 296 56.4 Province 4 271 55.2 Province 5 351 67.1 Province 6 349 66.9 Province 7 398 76.5 Age of Mother ns 15-19 346 58.5 20-24 946 62.4 25-29 567 60.8 30-34 236 61.3 35-49 117 57.4 Literacy Status Ns Literate 1,824 61.2 Illiterate 388 60.0 Education Level Ns No schooling 392 57.3 Primary 274 60.2 Some secondary 854 61.9 SLC and above 692 62.3 Ethnicity * Brahmin/Chhetri 869 65.5 Dalit 406 62.3 Janajaties 754 60.9 Other Terai Castes and Religious Minorities 183 44.5 Wealth Quintile * Lowest 462 64.0 Second 478 65.6 Third 455 63.2 Fourth 422 58.1 Highest 395 54.0 Total 2,212 61.1 95% Confidence Interval (58.9-63.0) *Significant at <0.05 level ns= not significant 1Total includes only those children who were born alive.

58 10.2 Exclusive Breastfeeding Practices

Table 10.3: Percent Distribution of RDW Who Exclusively Breastfed Their Child Under Six Months of Age by Background Characteristics Child Fed Only Breastmilk the Background Characteristics Day Before the Survey (N=1,387)1 n % Sex of the Child ns Male 469 63.9 Female 420 64.3 Ecological Zone * Mountain 231 69.8 Hill 389 72.8 Terai 269 51.5 Province * Province 1 114 59.1 Province 2 100 54.1 Province 3 101 52.6 Province 4 129 62.3 Province 5 134 69.4 Province 6 161 78.9 Province 7 150 70.4 Age of Mother ns 15-19 176 69.0 20-24 376 64.6 25-29 206 60.4 30-34 80 64.0 35-49 51 60.7 Literacy Status ns Literate 731 63.8 Illiterate 158 65.3 Education Level ns No schooling 160 63.0 Primary 116 69.9 Some secondary 350 65.3 SLC and above 263 61.0 Ethnicity ns Brahmin/Chhetri 328 65.1 Dalit 177 67.8 Janajaties 302 64.0 Other Terai Castes and Religious Minorities 82 54.7 Wealth Quintile * Lowest 211 74.6 Second 211 72.0 Third 178 63.1 Fourth 162 59.1 Highest 127 49.8 Total 889 64.1 95% Confidence Interval (61.3-66.8) *Significant at <0.05 level ns= not significant 1The total includes only those children who were less than 6 months of age at the time of the survey and were fed only breastmilk the preceeding day of survey.

59 10.3 Introduction of Complementary Foods

Table 10.4: Percent Distribution of RDW by BackGround Characteristics Who Had Introduced the Complementary Food to Their Child Age 6-8 Months Children Age 6-8 Months Fed Complementary Food the Day Background Characteristics Before the Survey (N=757)1 n % Sex of Child ns Male 346 87.6 Female 316 87.3 Ecological Zone * Mountain 160 91.4 Hill 263 91.3 Terai 239 81.3 Province * Province 1 82 82.0 Province 2 71 71.7 Province 3 121 91.0 Province 4 92 91.1 Province 5 99 94.3 Province 6 107 93.9 Province 7 90 85.7 Age of Mother ns 15-19 102 83.6 20-24 285 89.1 25-29 167 87.9 30-34 78 86.7 35-49 30 85.7 Literacy Status * Literate 560 89.3 Illiterate 102 78.5 Education Level * No schooling 109 80.1 Primary 78 93.0 Some secondary 233 86.9 SLC and above 242 93.4 Ethnicity * Brahmin/Chhetri 280 92.7 Dalit 109 85.8 Janajaties 225 87.2 Other Terai Castes and Religious Minorities 48 86.6 Wealth Quintile ns Lowest 135 88.8 Second 116 84.7 Third 132 87.4 Fourth 118 84.9 Highest 161 90.4 Total 662 87.5 95% Confidence Interval (84.6-89.8) *Significant at <0.05 level ns= not significant 1Total includes only those children who were 6-8 months of age.

60 10.4 Minimum Dietary Diversity

Table 10.5: Percent Distribution by Background Characteristics of RDW Who Had Been Given Food From Four or More Groups for Their Children Ages 6-11 Months the Day Prior to the Survey Children Age 6-11 Months Fed Food From Four Groups or More the Day Background Characteristics Before the Survey (N=1,610)1 n % Sex of the Child ns Male 265 31.6 Female 246 31.9 Ecological Zone * Mountain 107 30.7 Hill 229 37.2 Terai 175 27.0 Province * Province 1 63 28.9 Province 2 35 14.8 Province 3 90 34.0 Province 4 82 39.4 Province 5 113 47.7 Province 6 69 29.5 Province 7 59 27.8 Age of Mother * 15-19 79 32.1 20-24 245 35.5 25-29 113 27.1 30-34 53 28.5 35-49 21 29.6 Literacy Status * Literate 469 35.2 Illiterate 42 15.1 Education Level * No schooling 48 16.3 Primary 37 18.2 Some secondary 218 35.5 SLC and above 208 41.8 Ethnicity * Brahmin/Chhetri 238 39.4 Dalit 79 27.9 Janajaties 169 31.3 Other Terai Castes and Religious Minorities 25 13.7 Wealth Quintile * Lowest 55 18.5 Second 85 28.1 Third 100 31.4 Fourth 128 38.1 Highest 143 40.3 Total 511 31.7 95% Confidence Interval (29.2-34.4) *Significant at <0.05 level ns= not significant 1The total includes only those children who were 6-11 months of age.

61 10.5 Types of Complementary Foods

Table 10.6: Proportion of RDW Reporting Food and Liquid Consumed by Children in the Preceding Day of the Survey 0-1 2-3 4-5 6-7 8-9 10-11 Types of Food months months months months months months % % % % % % Food from grains 1.2 3.2 26.1 80.0 95.5 97.6 Food made from roots and tubers 0.2 - 3.8 25.2 47.7 53.9 Legumes and nuts 0.2 0.4 8.5 42.7 57.4 67.4 Vitamin A rich fruits and vegetables - 0.2 4.0 23.6 36.5 47.1 Other fruits and vegetables - 0.2 4.2 15.3 29.1 25.3 Meat/Fish/Eggs - - 3.0 16.1 25.9 29.1 Dairy product - - 1.2 2.0 4.7 5.4 Other milk 3.6 9.0 22.7 47.6 47.7 47.7 Other liquid 0.5 0.6 8.3 24.2 35.2 37.1

62 CHAPTER 11: POSTPARTUM FAMILY PLANNING

Postpartum family planning (FP) is an important issue directly linked to the health of mothers and newborns. Postpartum family planning not only prevents unwanted pregnancy, but also the birth spacing of three to five years between two children ensures care and attention for each child. Postpartum family planning also is focused on because of the high chances of conceiving following the sixth week of delivery and because unprotected intercourse during postpartum amenorrhea also can result in pregnancy despite the perception of a reduced chance. Thus, the period after birthing a child is crucial to discuss family planning and birth spacing with RDW.

11.1 Family Planning Practices

Table 11.1: Percent Distribution of Family Planning Practice After Birth of the Last Child Reported by RDW N % Received counseling on family planning after the birth of the last child Yes 2,106 57.5 No 1,555 42.4 Total 3,661 100.0 Use a family planning method after the birth of the last child Yes 1,452 39.7 No 2,209 62.3 Total 3,661 100.0 Types of FP method used Female Sterilization 68 4.7 Male Sterilization 16 1.1 Pill 117 8.1 IUD (Copper T) 25 1.7 Depo-Provera (Sangini) 526 36.2 Implant (Jadelle) 82 5.6 Condom 392 27.0 Periodic abstinence 21 1.4 Withdrawal 200 13.8 LAM 5 0.3 Total1 1,452 100.0 Months when FP method started after birth of the last child Within less than 3 months 477 32.9 Within 3-6 months 779 53.6 After 6 months 196 13.5 Mean no. of months when FP method started 3.84 Total1 1,452 100.0 1The total includes only those RDW who had used the FP methods at any time after the last child’s birth.

63 CHAPTER 12: CONCLUSIONS

The survey in 21 CHX implementing districts among 3,661 RDW shows that the coverage of MNH program is high in the study areas. However, there are high variations in service utilization by geographic, demographic and socio-cultural factors. The MNH indicators, such as ANC visits, was found nearly universal and three-fourths had attended at least four times with over four in ten attending the ANC during all specified months (4th, 6th, 8th and 9th). In addition, RDW's practice on other aspects of ANC, such as taking TT vaccine and consumption of iron folic tablets during pregnancy, also was high. The study shows a higher level of knowledge among RDW about danger signs that may appear during antenatal and postnatal period. It also is encouraging to note that nearly three-fourths of the deliveries were institutional delivery. Further, it is reassuring to note that CHX component in the newborn care program has been successful in achieving a high coverage and compliance of application among the newborns. The study results demonstrate good knowledge and practices among RDW regarding newborn care.

The study further notes that while many indicators show good status of MNH care and practices in the community, there are some areas where the program should put more focus on. The study shows that many RDW did not seek care when one of the danger signs appeared during their pregnancy or delivery. Moreover, the survey result shows, for example, that after encountering the danger signs, 17 percent of the RDW who encountered problems in their last pregnancy took no action to resolve them, and 15 percent who encountered a problem during delivery took no action. This finding reflects the need for more awareness in the community regarding women seeking health care.

The practice of a home visit by a FCHV also was low: only one third of RDW receive a home visit by FCHVs, 18 percent received home visits twice, and 9 percent received home visits thrice within six weeks of delivery. Similarly, the practice of postpartum checkups also was low in both institutional and home deliveries. For example, among all institutional deliveries, less than half had postpartum checkups where only 27 percent had two checkups within six weeks of delivery. Among RDW who had given birth at home, 69 percent didn't go for postpartum checkups. Though intake of iron folic acid tablets during pregnancy was high, intake of iron folic acid tablets during postpartum was low with 32 percent of RDW not having taken any iron-folic-acid tablets during the postpartum period. Considering these findings, the MNH program in the study district needs to strengthen the program and create an enabling environment for better utilization of MNH services by women in the community.

The study findings on the place of delivery of RDW's last child are highly encouraging since the practice of institutional delivery in study districts was much higher than the national figure of 57 percent in 2016 (MoHP, 2016). The MNH programs in the study districts, however, needs to continue their efforts of promoting institutional delivery among the community people in the Mountain region and Province 2 since a high percentage of deliveries are still taking place at home in those areas. For example, only about 57 percent of RDW in Province 2 had delivered their child in health facilities.

The study findings also demonstrate a need to strengthen the MSC coverage as an important aspect of the MNH program. For example, only 4 percent of RDW had heard of MSC and among those who had heard of it, only 44 percent had received it. Therefore, this finding calls for the program to put more effort in providing knowledge about MSC and ensuring adequate supply to and utilization of drug by the delivering mothers.

Additionally, the study notes as an issue that there were still many newborn cases across the study districts where several types of substances other than CHX were applied in the cord stump of the child.

64 REFERENCES

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65 Appendices

DISCLAIMER The author’s views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States Government.

APPENDIX 1: LIST OF SELECTED CLUSTERS

S.N. District Cluster S.N. District Cluster 1 Nawalparasi Naya Belhani 42 Nawalparasi Shivmandhir 2 Sindhupalchowk Thumpakhar 43 Salyan Phalabang 3 Chitwan Pithuwa 44 Salyan Phalabang 4 Sindhupalchowk Sangachowk 45 Chitwan Dibayanagar 5 Chitwan Bharatpur Municipality 46 Sindhupalchowk Tatopani 6 Myagdi Devisthan 47 Nawalparasi Mukundapur 7 Myagdi Devisthan 48 Dhading Khari 8 Chitwan Jutpani 49 Chitwan Bharatpur Municipality 9 Sindhupalchowk Bhimtar 50 Dhading Jaharlang 10 Dhading Nilkantha 51 Dhading Jaharlang 11 Mustang Lete 52 Nawalparasi Rajahar 12 Mustang Lete 53 Salyan Kalagaun 13 Sindhupalchowk Kiwool 54 Salyan Kalagaun 14 Sindhupalchowk Fatakshila 55 Chitwan Mangalapur 15 Dhading Khari 56 Sindhupalchowk Kiwool 16 Dhading Benighat 57 Chitwan Bharatpur Municipality 17 Sindhupalchowk Marming 58 Sindhupalchowk Marming 18 Sindhupalchowk Haibung 59 Sindhupalchowk Thumpakhar 19 Dhading Benighat 60 Sindhupalchowk Bhimtar 20 Sindhupalchowk Tatopani 61 Chitwan Pithuwa 21 Nawalparasi Shivmandhir 62 Chitwan Shaktikhor 22 Jumla Guthichaur 63 Chitwan Shaktikhor 23 Jumla Guthichaur 64 Sindhupalchowk Sangachowk 24 Chitwan Bhandara 65 Chitwan Mangalapur 25 Jumla Kudari 66 Sindhupalchowk Haibung 26 Jumla Kudari 67 Nawalparasi Devchuli 27 Nawalparasi Amarapuri 68 Myagdi Muna 28 Dailekh Belpata 69 Myagdi Muna 29 Dailekh Kashikand 70 Dailekh lalikanda 30 Nawalparasi Gaidakot 71 Dhading Dhusa 31 Dailekh Tolijaisi 72 Salyan Damachaur 32 Nawalparasi Gaidakot 73 Salyan Damachaur 33 Dailekh Lalikanda 74 Chitwan Bharatpur Municipality 34 Nawalparasi Jaubari 75 Myagdi Ghar 35 Dailekh Padhukastan 76 Myagdi Ghar 36 Nawalparasi Amarapuri 77 Chitwan Dibayanagar 37 Dailekh Dullu 78 Myagdi Room 38 Nawalparasi Devchuli 79 Myagdi Room 39 Dailekh Kashikand 80 Chitwan Bhandara 40 Salyan Laxmipur 81 Dhading Nilkantha 41 Salyan Laxmipur 82 Mustang Jomsom

S.N. District Cluster S.N. District Cluster 83 Mustang Jomsom 120 Myagdi Arthunge 84 Nawalparasi Jaubari 121 Myagdi Arthunge 85 Dhading Salyankot 122 Salyan Badagaun 86 Dhading Salyankot 123 Jumla Chandanath 87 Mustang Tukuche 124 Myagdi Jyamrukot 88 Mustang Tukuche 125 Myagdi Pulachaur 89 Sindhupalchowk Fatakshila 126 Myagdi Pulachaur 90 Myagdi Jyamrukot 127 Mustang Muktinath 91 Mustang Kagbeni 128 Mustang Muktinath 92 Mustang Kagbeni 129 Jumla Dhapa 93 Dhading Dhusa 130 Jumla Mahat 94 Dhading Marpark 131 Mustang Marpha 95 Dhading Marpark 132 Mustang Marpha 96 Chitwan Jutpani 133 Dang Tulsipur Municipality 97 Jumla Chandanath 134 Argakhanchi Kimadada 98 Nawalparasi Naya Belhani 135 Rautahaut Gaur Municipality 99 Salyan Dhakadham 136 Mustang Chusang 100 Salyan Dhakadham 137 Mustang Ghami 101 Salyan Badagaun 138 Mustang Ghami 102 Nawalparasi Mukundapur 139 Mustang Chhoser 103 Salyan Khalanga 140 Mustang Chhoser 104 Salyan Khalanga 141 Mustang Lomangthang 105 Salyan Sinwang 142 Mustang Kunjo 106 Salyan Sinwang 143 Mustang Kowang 107 Dailekh Tolijaisi 144 Palpa Tansen Municipality 108 Dailekh Salleri 145 Palpa Tansen Municipality 109 Dailekh Dullu 146 Sankhuwasabha Khadbari Municipality 110 Dailekh Salleri 147 Morang Biratnagar Sub Metropolitian 111 Dailekh Belpata 148 Morang Biratnagar Sub Metropolitian 112 Dailekh Narayan Municipality 149 Palpa Khanichap 113 Nawalparasi Rajahar 150 Palpa Khanichap 114 Dhading Thakre 151 Jumla Mahat 115 Dhading Thakre 152 Jumla Dhapa 116 Dailekh Narayan Municipality 153 Parsa Birgunj Sub metro 117 Dailekh Padhukastan 154 Rautahaut Gaur Municipality 118 Jumla Badki 155 Mahottori Parsapateli 119 Jumla Badki 156 Parsa Birgunj Sub metro

S.N. District Cluster S.N. District Cluster 157 Mahottori Parsapateli 191 Morang Belbari 158 Jumla Pandawagufa 192 Morang Belbari 159 Jumla Talium 193 Argakhanchi Pathauti 160 Rautahaut BasbitiJingadiya 194 Mahottori Sarpallo 161 Rautahaut PiparaBhagawanpur 195 Parsa Birgunj 162 Palpa Nayarnamtales 196 Mahottori Gaushala 163 Palpa Nayarnamtales 197 Parsa Dhaubini 164 Dang Shreegaun 198 Rautahaut Dharahi 125 Myagdi Pulachaur 199 Rautahaut Kakanpur 126 Myagdi Pulachaur 200 Panchthar Aarubote 162 Palpa Nayarnamtales 201 Panchthar Aarubote 163 Palpa Nayarnamtales 202 Morang Urlabari 164 Dang Shreegaun 203 Sankhuwasabha Kharang 165 Dang Shreegaun 204 Sankhuwasabha Kharang 166 Morang Sisabanidhara 205 Sankhuwasabha Banawana 167 Morang Sisabanidhara 206 Panchthar Phidim 168 Mahottori Gaushala 207 Panchthar Phidim 169 Rautahaut BasbitiJingadiya 208 Morang Mrigauliya 170 Rautahaut PiparaBhagawanpur 209 Bajhang Masta 171 Kailali Dhangadi Municipality 210 Kailali Shreepur 172 Doti Mudhegau 211 Doti Kalikasthan 173 Doti Banja Kakani 212 Doti Tijali 174 Doti Lamikhal 213 Bajhang Masta 175 Bajhang Subeda 214 Bajhang Gaguda 176 Kailali Sreepur 215 Kailali Malakheti 177 Bajhang Subeda 216 Kailali Bhajani 178 Doti Mudhegau 217 Palpa Chhahara 179 Kailali Dhangadi Municipality 218 Dang Tribhuvan MP 180 Doti Banja Kakani 219 Dang Tribhuvan MP 181 Doti Lamikhal 220 Dang Hapur 182 Jumla Talium 221 Myagdi Baranja 183 Mahottori Sarpallo 222 Myagdi Baranja 184 Parsa Daubani 223 Palpa Hungi 185 Parsa Birgunj Sub metro 224 Argakhanchi Dibharna 186 Sankhuwasabha Khadbari Municipality 225 Dang Manpur 187 Sankhuwasabha Sitalpati 226 Palpa Dobhan 188 Sankhuwasabha Sitalpati 227 Palpa Chhahara 189 Panchthar Nagi 228 Argakhanchi Khilji 190 Panchthar Nagi 229 Argakhanchi Dhakawang

S.N. District Cluster S.N. District Cluster 230 Dang Manpur 272 Parsa Lakhanpur 231 Mahottori Mahottari 273 Doti Chattiwan 232 Parsa Lakhanpur 274 Kailali Godawari 233 Mahottori Sunderpur 278 Kailali Malakheti 234 Parsa Sadewa 275 Kailali Darakh 235 Rautahaut Kakanpur 279 Morang Kathmaha 236 Rautahaut Dharahi 280 Morang Kathmaha 237 Bajhang Kalukheti 281 Argakhanchi Balkot 238 Bajhang Kalukheti 282 Rautahaut Rangapur 239 Kailali Bhajani 283 Kailali Darakh 240 Doti Tijali 284 Mahottori Khairbanni 241 Doti Gaguda 285 Mahottori Khairbanni 242 Doti Kalikasthan 286 Panchthar Pauwasartap 243 Kailali Pathariya 287 Panchthar Pauwasartap 244 Kailali Pathariya 288 Panchthar Sarangdanda 245 Argakhanchi Pathauti 289 Panchthar Sarangdanda 246 Argakhanchi Thada 290 Panchthar Tharpu 247 Argakhanchi Thada 291 Panchthar Tharpu 248 Argakhanchi Dhakawang 292 Parsa Vauratar 249 Palpa Satyawati 293 Parsa Vauratar 250 Argakhanchi Dibharna 294 Bajhang Chaudhari 251 Dang Duruwa 295 Doti Dipayal silgadi MP 252 Bajhang Chaudhari 296 Bajhang Banjh 253 Sankhuwasabha Bana 297 Bajhang Banjh 254 Panchthar Limba 298 Sankhuwasabha Mamling 255 Sankhuwasabha Tamku 299 Sankhuwasabha Mamling 256 Morang Urlabari 300 Morang Hasandaha 257 Morang Mrigauliya 301 Morang Hasandaha 258 Morang Buddhanagar 302 Panchthar Durdimba 259 Morang Buddhanagar 303 Panchthar Durdimba 260 Panchthar Limba 304 Argakhanchi Siddhara 261 Sankhuwasabha Pathibhara 305 Argakhanchi Siddhara 262 Jumla Pandav gufa 306 Bajhang Pipalkot 263 Argakhanchi Khilji 307 Bajhang Pipalkot 264 Sankhuwasabha Pathibhara 308 Rautahaut ShitalpurBairgani 265 Rautahaut Rangapur 309 Rautahaut Masedawa 266 Sankhuwasabha Tamku 310 Mahottori Bardibas 267 Mahottori Dhamaura 311 Parsa Beriyabirta 268 Rautahaut ShitalpurBairgani 312 Rautahaut Masedawa 269 Mahottori Mahottari 313 Mahottori Bardibas 270 Parsa Sedhawa 314 Mahottori Dhamaura 271 Mahottori Sunderpur 315 Parsa Nirmalbasti 272 Parsa Lakhanpur 316 Parsa Beriyabirta 273 Doti Chattiwan 317 Palpa Dobhan 274 Kailali Godawari 318 Bajhang Kotbhairav 275 Kailali Darakh 319 Doti Gagauda 276 Argakhanchi Balkot 320 Doti Dipayal silgadi MP 277 Kailali Godawari 321 Doti Chattiwan

84 S.N. District Cluster 322 Parsa Nirmalbasti 323 Bajhang Deulekh 324 Palpa Satyawati 325 Palpa Hungi 326 Palpa Archale 327 Palpa Archale 328 Dang Hapur 329 Dang Bela 330 Dang Bela 331 Dang Purandhara 332 Sankhuwasabha Diding 333 Sankhuwasabha Diding 334 Argakhanchi Kimadada 335 Kailali Tikapur Municipality 336 Kailali Tikapur Municipality 337 Dang Tulsipur Municipality 338 Dang Duruwa 339 Dang Purandhara 340 Bajhang Kotbhairav

85 APPWNDIX 2: EVALUATION SCOPE OF WORK

A Survey on Chlorhexidine Coverage and Compliance and Essential Newborn Care Practices in Nepal, 2017

1. Background

Nepal is the first country in the world to scale up 4 percent Chlorhexidine (CHX) use for newborn cord care as a routine essential newborn care practice. As of September 2016, the intervention has reached both health facility and community level in 58 of the 75 districts, and in the birthing facilities of an additional 24 districts. CHX is primarily implemented as a component of the Community-Based Integrated Management of Newborn and Childhood Illness (CB-IMNCI) package. Randomized Controlled Trials conducted in Nepal, Bangladesh and Pakistan showed that use of chlorhexidine on the umbilical cord stump of newborns reduces newborn mortality by 23 percent and omphalitis by 68 percent. Nepal is also globally recognized as the first country to manufacture 4 percent CHX gel for use on the umbilical cord stump of newborns.

The Family Health Division of the Department of Health Services (DOHS) of the Ministry of Health and Population (MOHP) of Nepal piloted the use of CHX as one of the components of essential newborn care in three districts in 2009/2010. The CHX gel was distributed by Female Community Health Volunteers Chlorhexidine Implementation Status (FCHVs) to pregnant women, along with information on its importance and correct use during the eighth month of pregnancy. CHX was applied to newborns at facility births in those pilot districts. Evaluation of the pilot after one year of implementation showed that the coverage was 57 percent and compliance was 72 percent. After these encouraging results from the pilot, in December 2011 the MOHP decided to scale-up CHX nationwide as a component of the existing maternal, newborn, and child health programs. From the very beginning, CHX intervention has been receiving funding support from USAID and technical assistance from JSI R&T. Plan Nepal, Saving Newborn Lives, CARE, One Heart Worldwide, Health Right International, ADRA Nepal, and UNICEF also have been important contributors to the success of the CHX program in Nepal.

In districts where CHX is fully implemented, health facilities with birthing centers provide CHX services–both application at the time of birth and distribution during ANC visits in the eighth month of a pregnancy; the health facilities without a birthing center and the FCHVs distribute CHX tubes to pregnant women during the eighth month of pregnancy. All health facilities in program districts provide CHX to FCHVs to distribute to pregnant women. All FCHVs in program districts receive training on CHX use and distribution to pregnant women and their families. Once FCHVs are

86 trained on CHX, they distribute CHX tubes to pregnant women in the eighth month of pregnancy along with counseling on how to use CHX correctly in case of home delivery. Each FCHV receives a doll, CHX job aid (to distribute to pregnant women), and posters for using during health mothers group meeting and one-to-one counseling. CHD aims to scale up the use of CHX throughout the country, in all 75 districts, by the end of September 2017.

The CHX program includes community level and health facility level training, regular supply of the product, recording, reporting, monitoring and evaluation, and behavior change communication. To implement these program components, collaboration with different stakeholders, including the MOHP, development partners, professional societies, and the private sector is imperative.

Key indicators on CHX to be measured from this survey:

1. Percent of newborns receiving CHX applied to their umbilical cord disaggregated by facility and home births. 2. Percentage of mothers reporting of not applying any other substance besides CHX to the cord stump. 3. Percentage of mothers having knowledge of CHX. 4. Percentage of mothers who have skills for CHX use. 5. Percent of mothers/caretakers who have received CHX during their pregnancy.

Table: Mapping of districts by the maturity of Chlorhexidine intervention

Implementation Completion Year (58 districts with district-wide coverage) 2010- 2011 2012 2013 2014 2015 2016 Parsa Morang Taplejung Nuwakot Panchthar Dolakha Rolpa Dhankuta Sunsari Rasuwa Ramechhap Sindhupalchowk Jumla Sankhuwasabha Terathum Chitwan Kalikot Bhaktapur Bajura Saptari Bhojpur Tanahu Mugu Kathmandu Bajhang Mahottari Khotang Dadeldhura Dhading Darchula Sarlahi Udyapur Manang Banke Rautahat Kavre Mustang Dailekh Myagdi Bara Rukum Palpa Lamgunj Surkhet Nawalparasi Baglung Jajarkot Salyan Kapilvastu Bardiya Arghakhanchi Dolpa Dang Doti Humla Kailali Kanchanpur Baitadi 8 17 14 5 4 10

2. The Rationale for the Survey

The MOHP, USAID, and other partners have invested significant resources in introducing, scaling up, and sustaining CHX as a part of essential newborn care practices in Nepal. USAID funded approximately four million US dollars from 2012 to 2017 through the CHX Navi Care Project (CNCP) implemented by JSI R&T. As CHX is already included in the CB-IMNCI package and has been one of the essential medicines in Logistics Management Division’s procurement plan for nearly three years, it is important for CHD, USAID, and other partners to understand the coverage and compliance of CHX from a household level survey. The 2016 Nepal

87 Demographic and Health Survey also will provide coverage of CHX, but at the time of data collection, CHX was just introduced in birthing centers of 34 districts and were not yet distributed through FCHVs at the community level. Because of this reason, the 2016 NDHS will not provide a real coverage and compliance of CHX. That is why USAID is supporting a separate household level survey in 2017. In addition to assessing the coverage and compliance of the CHX, the proposed survey also will assess the overall newborn care and the birth preparedness practices at household levels, which will help CHD, FHD, USAID, and other partners for further refining the performance of the CB-IMNCI and the overall birth preparedness program.

3. Objectives of the Survey

The primary objective of the survey is to assess the coverage and compliance of CHX gel application in Nepal.

The secondary objectives of the survey are to: • Assess the newborn care practices and service utilization in Nepal. • Assess the status of birth preparedness and maternal service utilization in Nepal.

4. Survey Implementation Agency

This survey will be implemented by USAID’s Monitoring Evaluation and Learning (MEL) Project managed by CAMRIS International, located at Baluwatar, Kathmandu. The MEL project will form a survey team and will work closely with CHD, USAID, and CNCP to implement this survey.

The major roles and responsibilities of MEL include: • Carry out a desk review of available literature on CHX, essential newborn care, and birth preparedness. • Coordinate with USAID, CHD, and CNCP in finalizing survey methodology and instruments. • Seek ethical clearance from NHRC. • Finalize questionnaires, develop data program in tablets, and conduct a pre-test. • Conduct the survey. • Analyze data, share drafts, and finalize the report. • Present findings of the survey in appropriate forums.

The survey report will be published as CHD’s publication.

5. Methodology

The survey will be designed as a cross sectional, nationally representative household survey and the districts will be selected based on the maturity of CHX program. The sample districts should have district-wide program coverage and maturity of at least one year. Districts from all three ecological zones will be included to make representative estimates by the three ecological zones – Hill, Mountain, and Terai regions.

The respondents of this survey will be confined to women who had been or are currently married and who had given birth to a living baby or had delivered a still born (that had been in the gestation period for at least 28 weeks) in the year preceding the survey. The use of CHX will not be assessed among still born newborns, but it will be assessed for birth preparedness and newborn care practices.

88 The sample size for this survey should be appropriate to ensure comparability of estimates from the baseline carried out in three districts – Jumla, Banke, and Bajhang – where a total of 1,800 recently delivered women were interviewed. The sample size will be determined when the survey team is on board.

The survey instruments used in the “Chlorhexidine coverage and compliance survey in Banke, Jumla and Bajhang, 2012” will be updated and used in this survey. Data quality needs to be ensured at all levels. The final draft survey instruments should be tested in one or more VDCs and the learning should be incorporated in the final instruments.

The data collection for the survey should be carried out by teams of well-trained field supervisors and enumerators. Females should be given priority during recruitment. Training should be commenced immediately after the selection of field staff for duration of at least two weeks. There should be adequate practice sessions for the enumerators and field supervisors, and the training must be coordinated with CHD and CNCP/JSI. At districts, the survey team should coordinate with the District Public Health Offices.

6. Research Ethics

The MEL project is required to seek ethical clearance from Nepal Health Research Council’s Internal Review Board. The survey procedure should be designed to protect participants’ privacy, allowing for anonymous and voluntary participation. Before an interview, an informed consent needs to be obtained from each respondent.

7. Data Analysis

Data needs to be collected and processed in tablets. Data will be analyzed using SPSS or another statistical package, and descriptive statistics will be used to calculate data. Statistical tests will be carried out where necessary. The findings should be compared with surveys carried out in 2012 in the three districts. The survey implementation agency should keep CHD, USAID, and CNCP updated on the progress.

8. Timeline

S/N Activity Time 1 Sharing and finalization of SOW with CHD and partners December 2016 2 Sharing SOW with MEL and formation of Survey team January 2016 3 Evaluation Design and Questionnaire adaptation and finalization February 2017 4 Sending draft proposal for NHRC approval and clearance February 2017 5 Training to the field supervisors and enumerators May 2017 6 Data collection May-August 2017 7 Data processing and analysis September-October 2017 8 Sharing of the first draft (CHX) November 2017 9 Sharing of the final draft(CHX) November 2017 10 Submission of the final report and data sets November 2017 11 Final dissemination November2017

89 12. Point Persons

Following persons will be the point of contact for this survey.

CHD: Mr. Parshu Ram Shrestha, IMNCI Section Chief USAID: Ms. Sabita Tuladhar, MNCH Specialist Alternate: Dr. Shilu Adhikari, Sr. MNCH Advisor CNCP: Mr. Liladhar Dhakal, M&E Specialist Alternate: Samikshya Singh, Program Officer/M&E

References:

Family Health Division, Nepal Family Health Program II, New ERA. 2012. Coverage and Compliance of Chlorhexidine (Kawach) in Banke, Jumla and Bajhang Districts

Chlorhexidine for Umbilical Cord Care: A new, low-cost intervention to reduce newborn mortality. Edited by PATH for the Chlorhexidine Working Group. July 2014

Hodgins, S. Pradhan, Y.V. et al. Chlorhexidine for umbilical cord care: game-changer for newborn survival?

90 APPENDIX 3: DATA COLLECTION SUPPORT LETTER

91 APPENDIX 4: NEPAL HEALTH RESEARCH CENTER (NHRC) ETHICAL CLEARANCE

92 APPENDIX 5: PERSONNEL INVOLVED IN THE SURVEY(New ERA)

TECHNICAL AND ADMINISTRATIVE STAFF OF NEW ERA

Core Team Members Ms. Nira Joshi, Team Leader Mr. Kiran Acharya, Research Officer Ms. Meena Sitaula, Research Assistant

Data Processing Staff Ms. Sarmila Shrestha Prasai Ms. Sarita Vaidya Ms. Deepa Shakya Mr. Babu Raja Dangol

Administrative Staff Mr. Sujan Bhakta Shrestha Mr. Sanu Raja Shakya

FIELD DATA COLLECTION STAFF

Field Managers/Quality Control Staff Mr. Manoj Bikram Kathet Mr. Hari Bhakta Saud Mr. Durga Prasad Acharya Mr. Kamal Timsina

Field Supervisors Mr. Bishwas Neupane Mr. Tika Prasad Upadhyaya Mr. Dev Raj Nepal Mr. Umesh Dhakal Mr. Dhayan Bahadur Rai Ms. Anjana Kumari Dulal Mr. Krishna Prakash Sharma Ms. Asmita KC Mr. Nagendra Sha Ms. Basanti Karki Mr. Nawaraj Tiwari Ms. Binita Basnet Mr. Netra Bikram Thapa Ms. Durga Pudasaini Mr. Puspa Raj Lama Ms. Pratima Kharel Mr. Rabish Chandra Bhatta Ms. Rajani Basnet Mr. Ram Chandra Chaudhary Ms. Sanjita Humagain Mr. Ram Datta Pant Ms. Sarita Magar Mr. Rameshwor Raya Yadhav Ms. Sonam Shrestha Mr. Sanjaya Dangi Ms. Surachita Koirala Mr. Satish Kumar Thakur Ms. Sushila Khadka Mr. Shirjan Kumar Yadav Ms. Susma Regmi Mr. Shiva Kumar Mahato Ms. Urmila Upreti Mr. Shyam Sundar Prasad Ms. Yamuna Karki

93 APPENDIX 6: QUESTIONNAIRE

i. Screening Questionnaire I

A SURVEY ON COVERAGE AND COMPLIANCE OF CHX FINAL EVALUATION – 2017 (MOHP/JSI-CNCP/New ERA) SCREENING QUESTIONNAIRE – 1

Instructions to interviewer: Complete this Household Listing Form by interviewing the household head. If the household head is not present or otherwise unable to provide the required information, interview a senior member of the household and note their name in the table below.

Introduction 1) Cluster number: 2) Household number:

3) Name of the household head: ______

4) Name of the representative: ______/______/2074 5) Date of interview: day month year Interview completed ...... 1 Respondent refused to be interviewed ...... 2 5) Status of interview: Respondent was not at home ...... 3 Other (Specify)______...... 96

7) How many women (all women) of age 15-49 years live in your Total household? (resided in the house last night) 8) Please give me their name(s), marital status and age of the women who resided in the house last night. Line Name of the women Marital Status (3) Age If she has ever been married No. Currently Widow, Unmarried ask, has she been pregnant (2) married Separated, (pregnancy loss or live birth) in (1) Divorced (4) the last two years (i.e., since Baishakh 2072)? (5) Yes No 1. 1 2 3 1 2 2. 1 2 3 1 2 3. 1 2 3 1 2 4. 1 2 3 1 2 5. 1 2 3 1 2 6. 1 2 3 1 2 7. 1 2 3 1 2 8. 1 2 3 1 2 9. 1 2 3 1 2 10. 1 2 3 1 2 Screening Questionnaire -2 should be filled for a married woman who has been pregnant in the last 2 years (i.e., since Baishakh 2072). Screening Questionnaire -2 should not be filled out for other women.

ii. Screening Questionnaire II

Confidential only for research.

A Survey on Coverage and Compliance of CHX -FINAL EVALUATION 2017 (screening questionnaire 2 to find recently delivered women) (MOHP/JSI-CNCP/CAMRIS INTERNATIONAL /New ERA)

Introduction 1) District: ______2) VDC name and code: ______3) Ward No.: 4) Village and tole name: ______5) Cluster number: 6) Household number:

7) Name of household head: ______

8) Name and line number of the respondent: ______......

(From Screening 1)

Interviewer Visits 1 2 3 Last Visit

Date ____/____/2074 ____/____/2074 ____/____/2074 Day Day Month Year Day Month Year Day Month Year Month 2 0 7 4 Interviewer's Name ______Year

Result* ______Int. Code

Result*

Next Visit: Date ______Total no. of visit

Time ______

* Result code: 01 Complete Interview 02 Refuse Interview 03 Fixed Time for Next Visit

04 Not at Home 96 Other (Specify)______

Supervisor Office Editor Ke yed By

______Name Number Number Number

Introduction and Consent

Namaste! My name is………………. I am here from New ERA, a research organization based in Kathma ndu. On

behalf of the Ministry of Health – Child Health Division, we are collecting information on the health of women and babies in 21 districts of Nepal. This study has been approved by the Nepal Health Research Center (NHRC ). Your household has been randomly selected to participate.

If you agree to participate, during the interview I will ask you about your background and any recent preg nancies. We also will need to make some observations of the house and surrounding area.

We are inviting you to be a participant in this study. We value your opinions, and there are no wrong answers to our questions. We will need approximately an hour and a half hour of your time. There will be no risk of yo ur participating in the study. Your participation in this research is completely voluntary. You are free to withdraw your consent and discontinue participation in this study at any time. All information gathered will be strictly treated as confidential and will be used only for the study purposes. Your answers to my questions will be combined with answers from many other people, so that no one will know that the answers you give me today belong to you. The findings of this study will be used to make recommendations on how to improve care for women and babies in Nepal.

If you need further information, you can contact either Kiran Acharya (Kalopul, Kathmandu; email: [email protected]; Ph. No. 01-4413603) or Ganesh Sharma (CAMRIS International, Kathmandu; email, [email protected] ; Ph. No. 01-4439474, extension 111).

Your participation will be highly appreciated.

Are you willing to participate in the study? 1. Yes 0. No Exit Interview

Name of respondent: ______Signature: ______Date: ____/_____/2074

Signature of the interviewer: ______

Q. No. Question Response Go To 101 In what month and year were you born? Month ...... Month don't know ...... 98 Year ...... Year don't know ...... 9998 102 Age of respondent Completed years (15-49) ...... (Instruction: calculate from date of birth) →END Age <15 or >49 – circle 1 and end interview .. 1 Interview 103 How many times have you given birth to a live baby in the last two years (i.e., since Baishakh 2072)? Time 104 Have you ever had a pregnancy in the last Yes 1 two years (i.e., since Baishakh 2072) that did No 2 not end in a live birth? 105 Check Q103 and Q104, and circle below: Had a live birth or pregnancy loss post Baishakh 2072…………………….…………1 Had neither a live birth nor pregnancy loss post Baishakh 2072 2→ END Interview Now, I would like to record all of your pregnancies that have ended in the last two years, whether born alive, born dead, or lost before full term, starting with the last one you had.

Note: RECORD ALL THE PREGNANCIES IN Q106.STARTING FROM THE LAST ONE RECORD TWINS AND TRIPLETS ON SEPARATE LINES. No need to ask about current pregnancy. 1 2 3 Prior to the last Prior to the second to Last pregnancy pregnancy last pregnancy 106 How did the pregnancy Born alive =1 Born alive = 1 Born alive = 1 end? Was the baby born Born dead/pregnancy Born dead/pregnancy Born dead/pregnancy alive or born dead? loss =2→112 loss = 2→112 loss = 2→112 107 What name was given to the child? ______(Name) (Name) (Name) 108 Is (name) a boy or a girl? Boy = 1 Boy = 1 Boy = 1 Girl = 2 Girl = 2 Girl = 2 109 In what month and year Month: Month: Month: was (name) born? Year: Year: Year: 110 Is (name) still alive? Yes = → 115 Yes = → 115 Yes = → 115 No = 2 No = 2 No = 2 111 How old was (name) when he/she died? Day: 1. Day: 1. Day: 1.

(If less than one-month Month: 2. Month: 2. Month: 2. record in day) (Skip to 115) (Skip to 115) (Skip to 115) 112 In what month and year Month: Month: Month: did this pregnancy end? Year: Year: Year: 113 How many months did this pregnancy last? Month: Month: Month: (Record in completed (If >=7 x months go to (If >=7 x months go to (If >=7 x months go to months) 114. If <7 go to 116) 114. If <7 go to 116) 114. If <7 go to 116)

97 114 Did that baby show any Yes 1 Yes 1 Yes 1 signs of life (cry, move, or No 2 No 2 No 2 breathe) when it was born? (If yes, change 106 to 1, and ask question 108 and 109, and change 111 to 0 days) 115 Check Q109, 112, and Yes 1 Yes 1 Yes 1 113. No 2 No 2 No 2 Was the child born after Baishakh 2073 (born alive, or born dead and pregnancy lasted for 7 months or more)? 116 Have you been pregnant Yes 1 Yes 1 Yes 1 another time before this (Go to next column) (Go to next column) (Go to next column) pregnancy since Baishakh No 2 No 2 No 2 2072? (End Interview) (End Interview) (End Interview)

End Information: Administer Main Questionnaire to only one woman of the household who has been pregnant since Baishakh 2073, and the pregnancy lasted at least seven months (Q115=1). If there is more than one such woman in the household, then select one randomly and interview her.

98 i. RDW Questionnaire Confidential only used for research.

A Survey on Coverage and Compliance of CHX - Final Evaluation - 2073 (MOHP/JSI-CNCP, CAMRIS International/New ERA, Kathmandu, Nepal)

Questionnaire for Recently Delivered Women

Introduction 1) District name and code:______

2) Name of VDC/municipality and code: ______

3) Ward number:

4) Village name: ______

5) Cluster number:

6) Household number:

7) Name of the household head: ______

8) Name and line number of the respondent: ______......

(From Screening 2) Interviewer Visits 1 2 3 Final Visit

Date ____/____/2074 ____/____/2074 ____/____/2074 Day Day Month Year Day Month Year Day Month Year Month 2 0 7 4 Interviewer's Name ______Year

Result* ______Int. Code

* Result

Next Visit: Date ______Total no. of visit

Time ______

* Result code: 01 Complete Interview 02 Refuse Interview 03 Fixed Time for Next Visit

04 Not at Home 96 Other (Specify)______

Supervisor Office Editor Key ed By

______

Name Number Number Number

Name of Supervisor: ______Signature: ______Date: ______

08Check 1M Q106 pQ/bftfsf], Q107, 108, Q109, k[i7e"ld Q110, Q111, Q113, and Q114 in Screening Questionnaire Form 2: Enter in the table the line number, name, and the survival status of each birth from Baishakh 2073 or later, ask questions about the last birth from the screening questions.

S.No. Question Codes Go To QA From 106 Baby born alive or dead Born alive ...... 1 Born dead ...... 2 QG QB Name of the baby from 107 Name______

QC Sex of the baby from 108 Male ...... 1 Female ...... 2 QD Baby still alive from 110 Yes ...... 1 No ...... 2 QF QE Baby born after 2073 Baishakh from 109 Section 1 Age in months ......

QF Age at death from 111 Age when he/she died in months ...... If less than one month in Days ...... QG Early neonatal death from 114 Bab y showed signs of life then died (early neon atal death) ...... 1 Section 1 QH Baby showed no signs of life (stillborn) ...... 2 QH From 113 (pre gnancy loss after 7 months Yes ...... 1 or more) No ...... 2 End interview

Secti on 1: Respondent’s Ba ckground

Time interview starts: HH _ _ MM _ _ (24 hour)

Intervie wer: “Now I would like to ask som e questions about you and your household.” S.No. Question Code s Go To 101 Write the age of the respond ent from Q102 of screening 2 Age in completed years

102 Have you ever attended school? Yes ...... 1 No ...... 2 105 103 What is the highest class you completed? Class

Class code: 98 00 = Not completed grade 1 01- 10 = Indicate comple ted g rade 11 = Grade 11 or above compl eted 94 = School -bas ed preprimary education 98 = Don’t know 104 Interviewer: Check Q. 103 Grade 5 or below …………………….1 Grade 6 and above ……………………2 106 105 Now, I would like you to read aloud as much Cannot read at all ...... 1 of this sentence as you can. Able to read only parts of sentence ...... 2 "Churot khanu ramro bani hoina" Able to read whole sentence ...... 3 (Show card to the respondents) 106 What is your caste/ethnicity? (Write caste in space provided and fill Caste/Ethnicity ______box)

100

Section 2: Respondent’s Background (Socioeconomic Status)

Interviewer: “Now, I would like to ask some questions about your household.” S.No. Question Codes Go To 201 Does your household have the following items? (READ ALL) Yes No 1. Electricity/solar 1 2 2. Bicycle 1 2 3. Motorcycle 1 2 4. A mobile telephone 1 2 5. Landline telephone 1 2 6. Television 1 2 7. Radio 1 2 8. Refrigerator 1 2 9. Table 1 2 10. Chair 1 2 11. Bed 1 2 12. Sofa 1 2 13. Cupboard 1 2 14. Computer 1 2 15. Clock 1 2 16. Fan 1 2 17. Tempo (vehicle with three wheels) 1 2 18. Animal drawn cart 1 2 19. Car/truck (vehicle with four wheels) 1 2 202 What is the main source of drinking water Piped water for members of your household? Piped into dwelling ...... 1 Piped to yard/plot ...... 2 Piped to neighbor ...... 3 Public tap/standpipe ...... 4 Tube well or borehole ...... 5 Dug well Protected well ...... 6 Unprotected well ...... 7 Water from spring Protected spring ...... 8 Unprotected spring ...... 9 Rainwater ...... 10 Tanker truck ...... 11 Cart with small tank ...... 12 Surface water (river/dam/Lake/pond/ stream/canal/Irrigation channel) ...... 13 Bottled water ...... 14 Other (Specify) ______...... 96

101

S.No. Question Codes Go To 203 What type of toilet facilities does your Flush or pour flush toilet house have? Flush to piped sewer System ...... 1 Flush to septic tank ...... 2 Flush to pit latrine ...... 3 Flush to somewhere else ...... 4 Flush, don't know where ...... 5 Pit latrine Ventilated improved/Pit latrine ...... 6 Pit latrine with slab ...... 7 Pit latrine without slab/Open pit ...... 8 Composting toilet ...... 9 Bucket toilet ...... 10 Hanging toilet ...... 11 No facility/bush/field ...... 12 Other (Specify) ______..... 96 204 Main material of the house floor Natural floor Earth/sand ...... 1 RECORD OBSERVATION Record observation. Dung ...... 2 Rudimentary floor/Wood planks ...... 3 Palm/bamboo ...... 4 Finished floor Parquet or polished ...... 5 Wood ...... 6 Vinyl or asphalt strips ...... 7 Ceramic tiles ...... 8 Cement ...... 9 Carpet ...... 10 Other (Specify)______96 205 Main material of the house roof Natural roofing No roof ...... 1 RECORD OBSERVATION Thatch/palm leaf ...... 2 Rudimentary roofing/Rustic mat ...... 3 Palm/bamboo ...... 4 Wood planks ...... 5 Cardboard ...... 6 Finished roofing Galvanized sheet ...... 7 Wood ...... 8 Calamine/cement fiber ...... 9 Ceramic tiles ...... 10 Cement ...... 11 Roofing shingles ...... 12 Other (Specify) ______96

102

S.No. Question Codes Go To 206 Main material of the house walls Natural walls No walls ...... 1 Record observation. Cane/palm/trunks ...... 2 RECORD OBSERVATION Mud/sand ...... 3 Rudimentary walls Bamboo with mud ...... 4 Stone with mud ...... 5 Plywood ...... 6 Cardboard ...... 7 Reused wood ...... 8 Galvanized metal sheet ...... 9 Finished walls Cement ...... 10 Stone with lime/cement ...... 11 Bricks ...... 12 Cement blocks ...... 13 Wood planks/shingles ...... 14 Other (Specify)______.... 96

Section 3: FCHV Services: General and Antenatal

Interviewer: “Now I would like to ask you some questions about your FCHV and the services she provides to pregnant women.” S.No. Question Codes Go To 301 Do you know the FCHV who serves in your Yes ...... 1 area? No ...... 2 304 Prompt: Do you know the woman who Don't know ...... 8

gives out vitamin A to children under five in your area twice a year? 302 Did you meet the FCHV in your community Yes ...... 1 for services or advice during your last No ...... 2 304 pregnancy? 303 How many times did you meet with your FCHV during your last pregnancy outside of Number of times ...... the mothers’ group to receive services or Don't know ...... 98 advice? 304 Is there a health mothers' group in your area? Yes ...... 1 (if group exists but no meeting No ...... 2 401 conducted write No) Don't know ...... 8

305 Did you attend the health mothers' group Yes ...... 1 meeting during your last pregnancy? No ...... 2 401 306 How many times did you attend the health mothers’ group when you were last Number of times ...... pregnant? Don't know ...... 98 307 What did you discuss in the health mother's Navi Malam ...... 1 group meeting? Newborn care ...... 2 Child care ...... 3 (CIRCLE ALL RESPONSES GIVEN Immunization ...... 4 Nutrition ...... 5 Institutional delivery...... 6 Others (specify) ______... 96 Don’t remember ...... 98 Nothing ...... 0

103 Section 4: SBCC/Chlorohexidine

S.N. Question Codes Go To 401 Have you heard about Chlorhexidine/Navi Malam/Kawach from the Yes No following sources? (multiple answer possible) Prompt the question

1. FCHV 1 2 2. Health worker 1 2 3. Friends/relatives/neighbor 1 2

4. Pregnant women/mother’s group 1 2 5. Radio 1 2 If all =2, 6. Television 1 2 Go to 404 7. Poster 1 2

8. Sticker 1 2 9. Hoarding board 1 2 10. Wall painting 1 2 11. Job aid/action card 1 2 (ask if 401.5=1) Kantipur FM ...... 1 402 Which radio station(s)? Image FM ...... 2 (Multiple responses possible) Local FM (Specify) ______...... 3 Others (Specify)______...... 96 Don’t know ...... 98 (ask if 401.6=1) Kantipur TV ...... 1 403 Which television station's)? Nepal TV ...... 2 (Multiple responses possible) Others (Specify) ______...... 96 Don’t know ...... 98 404 Can you tell me, what is Navi Malam/Kawach To prevent infections in the umbilical used for? cord of newborns ...... 1 To reduce risk of death ...... 2 (multiple responses possible) Other (Specify) ______...... 96 Don’t know ...... 98 405 By which month of your pregnancy should a Month ...... woman obtain Navi Malam? Don't know ...... 98 406 From which sources can you obtain Navi FCHV ...... 1 Malam? Health facility ...... 2 Other (Specify) ______.... 96 Don’t know ...... 98 407 During your last pregnancy, were you Yes ...... 1 informed about Navi Malam/Kawach? No ...... 2 410 (show navi malam) 408 Who informed you about Navi FCHV...... 1 Malam/Kawach during pregnancy? Health workers...... 2 Others (Specify) ______...... 96 (multiple responses possible) Don’t know ...... 98 409 During which month of your pregnancy were Month ...... you first informed about Navi Don't know ...... 98 Malam/Kawach? 410 During your last pregnancy, were you given Yes ...... 1 412 or did you buy Chlorhexidine/ Navi No ...... 2 Malam/Kawach?

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S.No. Question Codes Go To 411 Reasons for not receiving/obtaining Not aware of Chlorhexidine/Navi Malam/Kawach ...... 1 Navi Malam stock out with FCHV ...... 2 I was away from home ...... 3 No contact with FCHV/don't know FCHV ...... 4 414 Navi Malam out of stock out in HF ...... 5 HF didn't give...... 6 Other (Specify) ______...... 96 Don't know ...... 98 412 From where did you obtain FCHV ...... 1 Chlorhexidine/Navi Malam/Kawach? Health facility ...... 2 Bought from a shop separately ...... 3 Bought from a shop in a CHDK ...... 4 Other (Specify)______...... 96 Don’t know ...... 98 413 At what month of pregnancy did you Month ...... get/receive Chlorhexidine/Navi Don't know ...... 98 Malam/Kawach? 414 What do you know about how to use Navi Wash hand with soap and water before Malam? applying Navi Malam ...... 1 Apply Immediately after cutting cord...... 2 (CIRCLE ALL RESPONSES GIVEN) Apply whole tube ...... 3 Massage Navi Malam in to cord ...... 4 (Multiple answer possible) Apply Navi Malam on stump and surrounding area ...... 5 After applying Navi Malam, keep stump untouched by clothes for a few minutes ...... 6 Do not apply anything else to the cord and keep it clean and dry ...... 7 Other (Specify)______...... 96 Nothing ...... 98

Section 5: Antenatal Care

Interviewer: “Now, I would like to ask you some questions about when you were pregnant prior to your most recent delivery.” S.No. Question Codes Go To 501 Did you receive antenatal care in a health Yes ...... 1 facility during your most recent pregnancy? No ...... 2 510

502 From whom did you receive care? Doctor ...... 1 Nurse/ANM ...... 2 Probe: Anybody else? HA/AHW/CMA ...... 3 Other (Specify) ...... 96 (CIRCLE ALL RESPONSES GIVEN) Don’t know ...... 98 503 How many times did you receive antenatal Number of times ...... care from a health worker during your most Don’t know/not sure ...... 98 recent pregnancy?

105

S.No. Question Codes Go To 504 In which months of pregnancy did you 1 month ...... 1 receive antenatal care? 2 months ...... 2 3 months ...... 3 (CIRCLE ALL RESPONSES GIVEN) 4 months ...... 4 5 months ...... 5 6 months ...... 6 7 months ...... 7 8 months ...... 8 9 months ...... 9 505 As part of your antenatal care during the pregnancy prior to your most recent delivery, were any of the following done at least Yes No Don't once? (Read each service, circle appropriate response) Know 1. Was your abdomen examined? 1 2 8 2. Did you receive deworming tablets? 1 2 8 3. Was your weight measured? 1 2 8 4. Was your blood pressure measured? 1 2 8 5. Did you give a blood sample? 1 2 8 6. Did you give a urine sample? 1 2 8 506 Where did you receive your last antenatal Government Hospital ...... 1 care for your most recent pregnancy? PHCC...... 2 Health post/sub-health post ...... 3 If source is hospital, health center, or Urban Health Clinic ...... 4 clinic, write the name of the place. PHC/OR clinic ...... 5 Probe to identify the type of source Pvt. Hospital/Clinic/N. Home ...... 6 and circle the appropriate code to the Pharmacy ...... 7 right. Community Health Unit ...... 8 Other (Specify)______...... 96 ______Don’t know ...... 98 NAME OF PLACE 507 During any of your antenatal care visits with health workers during your pregnancy prior to your most recent delivery, were you counseled on: (READ Don’t ALL RESPONSES) Yes No know 1. Danger signs for pregnant woman? 1 2 8 2. Delivery at a health facility 1 2 8 3. Using a skilled birth attendant? 1 2 8 4. Arranging emergency transport for delivery? 1 2 8 5. Arranging finances for delivery care? 1 2 8 6. About source/place of Emergency Obstetric Care? 1 2 8 7. Identify person to accompany mother to health facility in emergency? 1 2 8 8. Potential blood donors 1 2 8 9. Applying Navi Malam to cord stump immediately after child birth? 1 2 8 10. Applying nothing to the cord after applying Navi Malam? 1 2 8 11. Danger signs during delivery? 1 2 8 12. Make post-natal visit to a health facility or outreach clinic? 1 2 8 13. Danger signs for postpartum period? 1 2 8 14. Anyone touching newborn to wash hands with soap and water first 1 2 8 15. Wrap the newborn in a clean and dry cloth right after delivery? 1 2 8 16. Do not bathe the newborn within 24 hours? 1 2 8 17. Breastfeed the newborn within 1 hour after birth? 1 2 8 18. Exclusive breastfeeding? 1 2 8 19. continue breastfeeding until the child is 2 years old? 1 2 8 20. Danger signs in newborn? 1 2 8 21. Skin to skin contact? 1 2 8 22. Maternal incentive scheme 1 2 8

106 23. Immunization schedule? 1 2 8 24. Postpartum family planning 1 2 8 508 Did you receive TD injection when you Yes ...... 1 were pregnant prior to your most recent No ...... 2 510 delivery? Don't know ...... 8 509 How many times did you receive Number of shots ...... immunization against tetanus (TD) during Don’t know/not sure ...... 98 that pregnancy? 510 Were you given or did you buy any iron and Yes ...... 1

folic acid tablets when you were pregnant No ...... 2 512 prior to your most recent delivery? Do not know ...... 8 SHOW IRON TABLETS 511 During the whole pregnancy, for how many Number of days ...... days did you take the iron and folic tablets? Don’t know/not sure ...... 98 512 Where would you go for care if you have Government Hospital ...... 1 danger signs while you are pregnant? PHCC ...... 2 Urban health clinic ...... 3 Prompt: anywhere else? Health post/sub-health post ...... 4 Community health unit ...... 5 PHC/ORC ...... 6 (CIRCLE ALL RESPONSES GIVEN) Private Hospital/Clinic/N. Home ...... 7 Pharmacy ...... 8 FCHV ...... 9 TBA ...... 10 Traditional healer 11 Nowhere (treatment at home) ...... 12 Nowhere (would not seek treatment) ...... 13 Other (Specify)______...... 96 Don’t know ...... 98 513 What are the symptoms during pregnancy Blurred vision ...... 1 indicating the need to seek immediate care? Severe lower abdominal pain ...... 2 Severe headache ...... 3 Probe: Any others? Convulsion ...... 4 Swelling of hands and face ...... 5 (CIRCLE ALL RESPONSES GIVEN) Vaginal spotting or bleeding ...... 6 No movement of tetus inside the womb ...... 7 Other (Specify)______...... 96 Don't know ...... 98 514 When you were pregnant, did you experience any of the following problems at any time? (Read out all responses one after another) (Record all

responses accordingly.) Yes No 1. Blurred vision? 1 2 2. Severe lower abdominal pain? 1 2 If all res- 3. Severe headache? 1 2 ponse 4. Convulsion? 1 2 = 2 go 5. Swelling of the hands, body or face? 1 2 to 516 6. Any vaginal spotting or bleeding? 1 2

107

S.No. Question Codes Go To 515 Where did you seek care for the problems you Government Hospital ...... 1 mentioned above? PHCC ...... 2 Urban health clinic ...... 3 Prompt: anyone else? Health post/sub-health post ...... 4 Community health unit ...... 5 PHC/ORC ...... 6 (CIRCLE ALL RESPONSES GIVEN) Private Hospital/Clinic/N. Home ...... 7 Pharmacy ...... 8 FCHV ...... 9 TBA ...... 10 Dhami / jhankri ...... 11 Other (Specify) ______...... 96 Nowhere (treatment at home) ...... 12 Nowhere (no treatment sought) ...... 13 Don’t know ...... 98 Interviewer: “Now, I would like to ask you some questions about how you prepared for the arrival of your child during pregnancy.” 516 What kind of preparation did you make Saved money ...... 1 beforehand for the delivery of (NAME)? Arranged for transport ...... 2 Identified health facility ...... 3 Prompt: Anything else? Found blood donor ...... 4 Contacted with worker to help with delivery 5 (CIRCLE ALL RESPONSES GIVEN) Prepared clothes for the baby ...... 6 Other (Specify) ______.... 96 No preparation ...... 0 517 Did you receive a Jivan Surakchha (BPP) Card Yes ...... 1 when you were pregnant last time? No ...... 2 Don't know ...... 8 Show BPP CARD to respondent.

Section 6: Delivery Care Interviewer: “Now, I would like to ask you some questions about your most recent delivery.” S.No. Question Codes Go To 601 Who assisted with your most recent delivery? Doctor ...... 1 Staff Nurse/ ANM ...... 2 HA /AHW / CMA ...... 3 Prompt: Anybody else? TBA ...... 4 FCHV ...... 5 Relative/Friend ...... 6 (CIRCLE ALL RESPONSES GIVEN) Other (Specify)______...... 96 Nobody ...... 0 Don’t know ...... 98 602 Who else was present outside the delivery TBA ...... 1 room when the delivery took place? FCHV ...... 2 Friends/Neighbors ...... 3 Mother-in-law ...... 4 Prompt: Anybody else? Father-in-law ...... 5 Husband ...... 6 Mother ...... 7 (CIRCLE ALL RESPONSES GIVEN) Father ...... 8 Other relative ...... 9 Other (specify)______...... 96 Nobody ...... 0 Don’t know/cannot remember ...... 98

108 S.No. Question Codes Go To 603 Where did you give birth in your most recent Government Hospital ...... 1 delivery? PHCC ...... 2 Urban health clinic ...... 3 If the location is a hospital, health Health post/sub-health post ...... 4 center, or clinic, write the name of it. Community health unit ...... 5 Probe to identify the type of source and PHC/OR clinic ...... 6 circle the appropriate code to the right. Private Hospital/Clinic/N. Home ...... 7 Your home ...... 8 ______Other home ...... 9 Road ...... 10 609 NAME OF PLACE Jungle ...... 11 Other (Specify)______...... 96 (If Q. 410=2 don't ask Q. 604 and 605)

604 Did you or someone accompanying you carry Yes ...... 1 606 Navi Malam during your health facility visit for No ...... 2 delivery? Don't know ...... 8 606 605 Why not? Forgot to take it ...... 1 Did not think I needed to take to facility ...... 2 (Circle all options) Lost ...... 3 Don’t know ...... 98 Other ...... 96 606 Did the facility charge you any amount for the Yes ...... 1 delivery of your baby? No ...... 2 Don't know ...... 8 607 Was your child delivered by caesarean Yes ...... 1 609 section? No ...... 2 Prompt: did a doctor cut open your abdomen to deliver the baby? 608 Was it an instrumental delivery? Yes ...... 1 No ...... 2 Don't know ...... 8 609 Within the first hour after the delivery, did a Yes ...... 1 health worker give you an injection either in No ...... 2 the thigh or buttock or medication by No health worker present ...... 3 intravenous drip? Don't know ...... 8 610 What are the signs/symptoms during labor Labor longer than 8 hours ...... 1 indicating the need to seek immediate care? Appearance of baby’s hand/leg/ umbilical cord first ...... 2 Probe: Any other? Excessive bleeding before or after delivery ..... 3 Convulsion...... 4 (CIRCLE ALL RESPONSES GIVEN) Other (Specify)______. .... 96 Don't know ...... 98 611 During your delivery, did you experience any of the following problems at anytime? (Read out all responses one after another.) (Record all responses accordingly) Yes No 1. Prolonged labor (>8 hours)? 1 2 2. Appearance of baby’s hand/leg/umbilical cord first 1 2 3. So much bleeding that it wet your clothes and you feared it was life 1 2 If all =2 go to 701 threatening? 4. Convulsions? 1 2

109

S.No. Question Codes Go To 612 Where did you first seek care or who did you Government Hospital ...... 1 consult someone for the problems you PHCC ...... 2 mentioned above? Urban health clinic ...... 3 Health post/sub-health post ...... 4 Community health unit ...... 5 PHC/ORC ...... 6 Private Hospital/Clinic/N. Home ...... 7 Pharmacy ...... 8 FCHV ...... 9 TBA ...... 10 Dhami / jhankri ...... 11 Other (Specify) ______...... 96 Nowhere ...... 0 616 Interviewer: “Now, I would like to ask you some questions regarding whether you were referred for any of these problems.” 613 Did a health worker refer you or advise you Yes ...... 1 to go to a health facility for treatment for any No ...... 2 of the problems that you mentioned above No (Treatment received already) ...... 3 701 (Q610)? Don't know ...... 8 614 After you were advised to seek care, did you Yes ...... 1 go to any health facility? No ...... 2 616 615 Where did you go? Government Hospital ...... 1 PHCC ...... 2 Health post/sub-health post ...... 3 Urban Health Clinic ...... 4 PHC/ORC ...... 4 Private Hospital/Clinic/N. Home ...... 5 701 Community health unit ...... 6 Pharmacy ...... 7 Other (Specify)______...... 96 Don't know/don’t remember ...... 98 616 Why didn't you seek services from the health Don't know where to go ...... 1 facilities? Didn't have money ...... 2 Didn't have time ...... 3 (CIRCLE ALL RESPONSES GIVEN) No-one to accompany ...... 4 Don't have faith in HF ...... 5 HF closed ...... 6 No HW in HF ...... 7 Too far to go ...... 8 Other (Specify) ______...... 96

Section 7: Misoprostol

Interviewer: “Now, I would like to ask you some questions about misoprostol.” S.No. Question Codes Go To 701 Have you heard about misoprostol (MSC)? Yes ...... 1 (Show tablet) No ...... 2 Do not know/ do not remember ...... 98 801 702 What is the use of misoprostol (MSC)? Prevention of PPH ...... 1 Prevent from risk of death ...... 2 Contraction of Uterus ...... 3 Discharge of placenta ...... 4 Other (Specify) ______...... 96 Don't know ...... 98

110 S.No. Question Codes Go To 703 Did you receive MSC tablets when you were Yes ...... 1 pregnant? No ...... 2 706 If not, probe: Did you receive tablets like this (SHOW TABLET) during your last pregnancy? 704 From whom did you receive Misoprostol? FCHV ...... 1 Health workers ...... 2 Others (Specify) ______...... 3 705 How many tablets did you receive? No...... 707 Don’t know ...... 98 706 Why did you not receive MSC? Not aware of MSC ...... 1 MSC stock out with FCHV ...... 2 (Circle all options) I was away from home ...... 3 No contact with FCHV/don't know ...... 4 MSC stock out in HF ...... 5 708 HF didn't give ...... 6 Other (Specify) ______.... 96 Don't know ...... 98 707 How many months pregnant were you when you received MSC? Months ...... 708 When should a woman take MSC? After delivery of baby but before delivery of placenta ...... 1 Immediately after delivery of baby and placenta ...... 2 Other (Specify) ______.... 96 Don't know ...... 98 709 How many MSC tablets should a woman Number of tablets ...... take? Do not know ...... 8 710 When should a woman not take MSC During pregnancy ...... 1 tablets? If placenta comes out before taking MSC ...... 2 During labor but before delivery ...... 3 Probe: Any other conditions? Other (Specify) ______... 96 Don't know ...... 98 (CIRCLE ALL RESPONSES GIVEN) 711 Before the delivery, when you were still MSC should not be taken during pregnant, when did the HW/FCHV tell you pregnancy ...... 1 that you should take MSC? Taking MSC during pregnancy Probe: Any other? is dangerous ...... 2 Did not say anything ...... 3 (CIRCLE ALL RESPONSES GIVEN) Did not see FCHW/HW before delivery...... 4 Other (Specify)______...... 96 Don't remember/don’t know ...... 98 712 What problems/side effects could a woman Shivering ...... 1 face after taking MSC? Nausea ...... 2 Watery stool ...... 3 Probe: Any other? Fever ...... 4 Headache ...... 5 (CIRCLE ALL RESPONSES GIVEN) Other (Specify) ______.... 96 Don't know ...... 98 713 What should a woman do if she takes MSC Go to health facility ...... 1 but still experiences heavy bleeding? Other (Specify) ______.... 96 Don't Know ...... 98

111

S.No. Question Codes Go To 714 Check Q N. 603: Place of delivery Government Hospital ...... 1 PHCC ...... 2 Health post/sub-health post ...... 3 Urban health clinic ...... 4 801 PHC/OR clinic ...... 5 Private Hospital/Clinic/N. Home ...... 6 Community health unit ...... 7 Your home ...... 8 Other home ...... 9 Road ...... 10 Jungle ...... 11 Other (Specify) ______...... 96 715 Did you take the MSC tablets that you Yes ...... 1 received? No ...... 2 801 716 When did you take the MSC tablets? After delivery of baby but before delivery of placenta ...... 1 Immediately after delivery of baby and placenta ...... 2 Other (Specify) ______...... 96 717 How many MSC tablets did you take? One tablet ...... 1 Two tablets ...... 2 Three tablets ...... 3

Section 8: Postpartum Care

Interviewer: “Now, I would like to ask you some questions about your health after your most recent delivery.” S.No. Question Codes Go To Interviewer: “I would like to begin by asking you some questions about your FCHV and the postnatal services she provides.” 801 At the time of delivery or after the delivery, Yes ...... 1 did you receive a visit from the FCHV? No ...... 2 Don't know FCHV ...... 3 807 Don’t remember ...... 98 802 How long after the delivery did the first visit Days...... happen? Don't remember ...... 98 803 Did the FCHV make a second visit? Yes ...... 1 No ...... 2 Don't remember ...... 8 807 804 When did she make the second visit? Days...... Don't remember ...... 98 805 Did the FCHV make third visit? Yes ...... 1 No ...... 2 Don't remember ...... 8 807 806 When did she make the third visit? Days...... Don't remember ...... 98 807 How long after delivery did you first get a DAYS ...... checkup from a health worker? No checkup yet ...... 97

Don't know ...... 98 IF ON THE DAY OF DELIVERY

RECORD “00.”

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S.No. Question Codes Go To 808 Who checked on your health at that (FIRST) Doctor ...... 1 time? Nurse/ANM ...... 2 HA/AHW/CMA ...... 3 PROBE FOR THE MOST QUALIFIED FCHV ...... 4 PERSON. TBA ...... 5 Other (Specify)______.... 96 Don’t know / don’t remember ...... 98 809 How many times did a health professional Number of times: ...... check on your health during the six-week period after you gave birth? 810 Interviewer: Check question Q809 and Postnatal checkup more than once ...... 1 circle below: Postnatal checkup only once ...... 2 813 811 How long after delivery did the second DAYS ...... 1 checkup of your health take place? WEEKS ...... 2 IF LESS THAN ONE WEEK, RECORD Don’t know ...... 98 DAYS. 812 Who checked on your health at that Doctor ...... 1 (SECOND) time? Nurse/ANM ...... 2 HA/AHW ...... 3 PROBE FOR MOST QUALIFIED MCHW ...... 4 PERSON. TBA ...... 5 Other (Specify) ______..... 96 Don’t know / don’t remember ...... 98 813 Where did these checks take place? Government Hospital ...... 1 PHCC ...... 2 Prompt: Anywhere else? Health post/sub-health post ...... 3 Urban health clinic ...... 4 (CIRCLE ALL RESPONSES GIVEN) PHC/OR clinic ...... 5 Private Hospital/clinic/N. Home ...... 6 Community health unit ...... 7 Own home ...... 8 Others home ...... 9 Other (Specify)______..... 96 Interviewer: “Now, I am going to ask you some questions regarding care that you may have received at a health facility following your delivery.” 814 Which of the following activities were conducted by the health worker during your postnatal checkup during the six-week period after your Don't delivery? (READ ALL) Yes No Know 1. Examination of your abdomen? 1 2 8 2. Perineum examination? 1 2 8 3. Asked if you had excessive bleeding/severe abdominal pain? 1 2 8 4. Counseled you about family planning? 1 2 8 5. Counseled you about exclusive breastfeeding? 1 2 8 6. Counseled you about immunization? 1 2 8 7. Provided advice on skin to skin care? 1 2 8 8. Provided advice on thermal care? 1 2 8 9. Provided advice on cord care? 1 2 8 815 After your most recent delivery, for about Number of days ...... how many days did you take iron and folic Don’t know ...... 98 tablets?

SHOW IRON TABLETS (If not taken at all enter ‘00’)

113

S.No. Question Codes Go To 816 During the first 42 days after the delivery, Yes ...... 1 did you receive a Vitamin A dose like this? No ...... 2 SHOW VITAMIN A CAPSULE 817 What are the symptoms of the mother Fever ...... 1 indicating the need for her to seek Pain in lower abdomen or smelling immediate health care during the six-week vaginal discharge ...... 2 period after delivery? Excessive bleeding ...... 3 Probe: Anything else? Severe headache ...... 4 Convulsion ...... 5 (CIRCLE ALL RESPONSES GIVEN) Others (Specify)______.... .96 Don't know ...... 98 818 Following your delivery, did a health worker or FCHV counsel you on the following maternal danger signs or issues? Don't (READ ALL) Yes No Know 1. High fever? 1 2 8 2. Severe lower abdominal pain? 1 2 8 3. Smelly discharge? 1 2 8 4. Excessive bleeding? 1 2 8 5. Severe headache? 1 2 8 6. Convulsions? 1 2 8 7. Where to go for services? 1 2 8 819 How many days after delivery did you start Number of days ...... working outside your home? Not yet started to work outside home ...... 996 Don’t know ...... 998 820 Please tell me where you would go for Government Hospital ...... 1 health services if you experience danger PHCC ...... 2 signs during the six-weeks period after you Health post/sub-health post ...... 3 have delivered. Urban Health Clinic ...... 4 PHC/OR clinic ...... 5 (CIRCLE ALL RESPONSES GIVEN) Pvt. Clinic/n. Home ...... 6 Community health unit ...... 7 Pharmacy ...... 8 FCHV ...... 9 TBA ...... 10 Dhami/Jhankri ...... 11 Other (Specify)______... 96 Don’t know ...... 98

114 Section 9: Immediate Newborn Care

Interviewer: “Now, I would like to ask you some questions about the care of your child after delivery.” S.No. Question Codes Go To Interviewer: Check question QA and Yes ...... 1 confirm that recently delivered child No ...... 2 1001 901 was a live birth 902 Check Q N. 603: Place of delivery Government Hospital ...... 1 PHCC ...... 2 Health post/sub-health post ...... 3 Urban health clinic ...... 4 915 PHC/OR clinic ...... 5 Private Hospital/Clinic/N. Home ...... 6 Community health unit ...... 7 Your home ...... 8 Other home ...... 9 Road ...... 10 Jungle ...... 11 Other (Specify) ______...... 96 Interviewer: “Now, I would like to ask you some specific questions pertaining to the baby immediately following the delivery.” (Ask this question if this baby delivered at home. Check with QN 603. Only ask if option is 8, 9, 10 or 11) Yes ...... 1 908 903 Was a Clean Home Delivery Kit used during No ...... 2 delivery? Don't know ...... 98 (Show CHDK) 903a Check QG – confirm baby was not early Early neonatal death (Q. G=1) ...... 1 1001 neonatal death Not early neonatal death ...... 2

904 What instrument was used to cut the cord? New Blade ...... 1 906 Used Blade ...... 2 Knife ...... 3 Grass Cutter (hansiya) ...... 4 Weapon (khukuri) ...... 5 Scissor ...... 6 Other (Specify)______...... 96 Don’t know ...... 98 906 905 Was the instrument used to cut the cord Yes ...... 1 boiled before use? No ...... 2 Do not know/ cannot remember ...... 8 906 What was used to tie the cord? New ties ...... 1 Boiled string or thread ...... 2 Unboiled used string or thread ...... 3 Other (Specify)______...... 96 Don’t know ...... 98 907 On what surface was the cord cut? Plastic disc ...... 1 Metal coin ...... 2 Wood ...... 3 Other (Specify)______...... 96 Nothing...... 0 Don’t know ...... 98 908 How long after the birth of the baby was the Minutes ...... cord cut? Don't remember ...... 998

115 S.No. Question Codes Go To 909 Did the person who handled the baby, Yes ...... 1 assisting with the delivery, wash their hands No ...... 2 with soap and water first? Don't know ...... 98 910 Was your baby wiped off/dried before or Before ...... 1 after the placenta was delivered? After ...... 2 Not wiped...... 3 Don't know ...... 98 912 911 What type of cloth was used to wipe the Dry and clean ...... 1 baby? Wet and clean ...... 2 Dry and not clean ...... 3 Probe: Was it dry or wet? Was it Wet and not clean ...... 4 clean? Don't know ...... 98 912 Was your baby wrapped in a cloth or put on Before ...... 1 the mother's body and covered with a cloth After ...... 2 before or after the placenta was delivered? Not wrapped/put on the mother’s body ...... 3 914 Don't know ...... 98 913 What type of cloth was used to wrap or Dry and clean ...... 1 cover the baby? Wet and clean ...... 2 Dry and not clean ...... 3 Wet and not clean ...... 4 Don't know ...... 98 914 Where was the baby placed before the placenta On the floor ...... 1 was delivered? On the cot ...... 2 On the mother's abdomen or breast (skin to skin) ...... 3 With someone else ...... 4 Other (Specify)______.... 96 Don’t know ...... 98 915 What was applied in your baby's umbilical cord? Don't (Read one by one) Yes No Know 1. Oil 1 2 8 2. Ash 1 2 8 3. Vermillion 1 2 8 4. Ointment Ointment/Powder 1 2 8 5. Animal dung 1 2 8 6. Turmeric 1 2 8 7. Ghee 1 2 8 8. Milk 1 2 8 9. Curry soup 1 2 8 10. Navi Malam/Kawach 1 2 8 98. Other (Specify) ______1 2 8 Note: If Q. 915.10 = 1, Ask Q. 916 to 926, otherwise go to Q. 927.

916 How long after the umbilical cord cut was Immediately after cord was cut ...... 0 Navi Malam first applied? Minutes ...... Don’t know ...... 998 917 Who applied Navi Malam on the umbilical Mother ...... 1 919 cord stump of your baby? Family members ...... 2 FCHV ...... 3 Health worker ...... 4 Traditional birth attendant ...... 5 Other (Specify)______...... 96

116 S.No. Question Codes Go To 918 Did the person who applied Navi Malam tell Yes ...... 1 you that they were applying it? No ...... 2 Don’t know ...... 98 919 Check Q N. 603: Place of delivery Government Hospital ...... 1 PHCC ...... 2 Health post/sub-health post ...... 3 Urban health clinic ...... 4 927 PHC/OR clinic ...... 5 Private Hospital/Clinic/N. Home ...... 6 Community health unit ...... 7 Your home ...... 8 Other home ...... 9 Road ...... 10 Jungle ...... 11 Other (Specify) ______..... 96 920 Did the person applying Navi Malam wash Yes ...... 1 their hands with soap and water before No ...... 2 applying it? Don't know ...... 8 921 Was Navi Malam applied only on the stump, Stump only ...... 1 or also in the surrounding area of the Surrounding area only ...... 2 stump? Both in stump and surrounding area ...... 3 Don't know ...... 8 922 Was the whole content of the Navi Malam Whole content of the tube ...... 1 924 tube applied at once on your baby's stump, Part of the content of the tube ...... 2 or was only part of the amount from the Don't Know ...... 98 924 tube applied? 923 Why wasn’t the whole content of Navi Tube is more than enough for application once... 1 Malam in the tube applied at once? Thought more than one application is effective ...... 2 Probe: Any other reason? Did not know that whole content of the tube must be applied once ...... 3 (CIRCLE ALL RESPONSES GIVEN) Other (Specify)______..... 96 Don't know ...... 98 924 After applying Navi Malam, was the cord Yes ...... 1 stump of the baby massaged slowly by a No ...... 2 finger? Don't know ...... 98 925 How many times was Navi Malam applied on Times ...... the umbilical stump of your baby? Don't know ...... 98 926 After applying Navi Malam, was the cord Yes ...... 1 kept untouched for a few minutes? No ...... 2 Don't know ...... 98 927 Q. 410 and 915.10 check and circle Received Navi Malam but did not apply it ...... 1 appropriate code. Received Navi Malam and applied it ...... 2 929 Neither received nor applied it ...... 3 Not received but applied it ...... 4 Received Navi Malam but don't know if it was used...... 5 930 Did not receive Navi Malam and don't know If used ...... 6 If Q. 410=1 and Q. 915.10=2, circle 1 in Q. 927. If Q. 410=1 and Q. 915.10=1, circle 2 in Q. 927. If Q. 410=2 and Q. 915.10=2, circle 3 in Q. 927. If Q. 410=2 and Q. 915.10=1, circle 4 in Q. 927. If Q. 410=1 and Q. 915.10=8, circle 5 in Q. 927. If Q. 410=2 and Q. 915.10=8, circle 6 in Q. 927.

117 S.No. Question Codes Go To 928 You received Navi Malam (source from Q Delivered at a health facility but staff 410) but it was not applied to the cord did not apply ...... 1 stump of your baby. Why not? Family members/others were against of it 2 Forgot to apply ...... 3 Lost Navi Malam ...... 4 Did not think it was useful or necessary ...... 5 The HW/FCHV/TBA attending was against using it ...... 6 It is against cultural practice...... 7 Others (Specify) ...... 96 Don't know ...... 98 929 What did you do with the Navi Malam you Used it ...... 0 received during your pregnancy? Kept it ...... 1 Return to HF ...... 2 Return it to FCHV ...... 3 Threw it away ...... 4 Lost ...... 5 Other (Specify)______... 96 930 Was there any problem on the cord stump Yes ...... 1 of your baby within 28 days of birth? No ...... 2 933 931 What was the problem? Infection on the cord stump ...... 1 Delay in cord fall ...... 2 Probe: Any other problem? Other (Specify)______... 96 932 What did you do when there was a problem Used Navi Malam again ...... 1 with the baby’s cord stump? Visited a health facility/health worker ...... 2 Consulted a pharmacy ...... 3 Home remedy ...... 4 Other (Specify)______... 96 933 How many days after the cord was cut did it Days ...... fall? Don't know ...... 98 934 How long after birth before your baby was Within 1 hour ...... 1 bathed for the first time? 2-24 hours ...... 2 After 24 hours ...... 3 Don't know ...... 8 935 Did you ever breastfeed (NAME OF Yes ...... 1 BABY)? No ...... 2 939 936 How long after birth did you first put During the first hour after delivery...... 1 (NAME OF BABY) to the breast? More than 1 hour...... 2 Don’t know ...... 98 937 Did you give (NAME OF BABY) the first Yes ...... 1 liquid (begauti) that came from your No ...... 2 breasts? 938 In the first three days after birth was Yes ...... 1 (NAME) given anything to drink other than No ...... 2 breast milk? 939 Interviewer: Check question QD and Yes ...... 1 confirm that respondent has a live No ...... 2 1001 infant born after 2073 Baishakh Don't ask if 935=2 940 Are you still breastfeeding (NAME)? Yes ...... 1 No ...... 2

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S.No. Question Codes Go To 941 Now I would like to ask you about liquids or foods that (NAME) had yesterday during the day or at night. I am interested in whether your child had the item I mention even if it was combined with other foods. Don't Did (NAME) (drink/eat): Yes No know a) Plain water? 1 2 8 b) Juice or juice drinks? 1 2 8 c) Soup? 1 2 8 d) Milk, such as tinned, powered, or fresh animal milk? 1 2 8 IF YES: How many times did (NAME) drink milk? Number of times IF 7 OR MORE TIMES, RECORD “7.” drink milk e) Infant formula like Lactogen? 1 2 8 IF YES: How many times did (NAME) drink infant formula? Number of times IF 7 OR MORE TIMES, RECORD “7.” drank formula f) Any other liquids? 1 2 8 g) Yogurt? 1 2 8 IF YES: How many times did (NAME) eat yogurt? Number of times IF 7 OR MORE TIMES, RECORD “7.” ate yogurt h) Any fortified baby food like Cerelac, Nestrum, Champion, etc? 1 2 8 i) Roti, rice, maize, millet, noodles, porridge, or other foods made 1 2 8 from grains? j) Pumpkin, carrots, squash, or sweet potatoes that are yellow or 1 2 8 orange inside? k) White potatoes, white yams, colocasia, or any other foods made 1 2 8 from root? l) Any dark green, leafy vegetables like spinach, amaranth leaves, 1 2 8 ormustard leaves? m) Ripe mangoes, papayas, or apricots? 1 2 8 n) Any other fruits or vegetables? 1 2 8 o) Liver, kidney, heart, or other organ meats? 1 2 8 p) Any meat, such as pork, lamb, goat, chicken, or duck? 1 2 8 q) Eggs? 1 2 8 r) Fresh or dried fish or shellfish? 1 2 8 s) Any foods made from beans, peas, lentils, or nuts? 1 2 8 t) Cheese or other food made from milk? 1 2 8 u) Any other solid, semi-solid, or soft food (jaulo, lito, sarbottam 1 2 8 pitho, etc.)? 942 How many times did (NAME) eat solid, semi-solid, or soft foods yesterday during Number of times ...... the day or at night? Don’t know ...... 98

119 Section 10: Newborn Care During the First Month

Interviewer: “Now, I would like to ask you some questions about the health of your child during the month after your most recent delivery.” S.No. Question Codes Go To 1001 What symptoms that a baby can Poor sucking or not able to feed ...... 1 experience within one month after being Convulsions/fits ...... 2 born do you believe indicatie the need to Fast breathing ...... 3 seek immediate health care for the baby? Severe chest indrawing ...... 4 Hypothermia ...... 5 Prompt: Any other symptoms? Fever ...... 6 Difficult to wake/lethargic/unconscious...... 7 (CIRCLE ALL RESPONSES GIVEN) Redness of skin around the cord ...... 8 Discharge from the cord ...... 9 Nasal flaring ...... 10 Grunting ...... 11 Bulging fontanelle ...... 12 Discharge from the eyes ...... 13 Skin pustules ...... 14 Other (Specify)______.... 96 Don’t know ...... 98 1002 Interviewer: Check questions QA, Baby still alive ...... 1 QD, QF and QG circle appropriate Baby born alive, then died at 2+ months...... 2 code Baby born alive, then died at 0-1 months ...... 3 Baby still born or died at birth ...... 4 1101 Interviewer: “I would like to start by asking you some detailed questions about the postnatal care that your most recently delivered child received." 1003 During the first four weeks or one month Yes ...... 1 after your most recent delivery, did a health No ...... 2 1009 professional or FCHV check your newborn’s health? 1004 How many times was your newborn's health Times ...... checked within the four weeks or one month after the delivery? 1005 How many days after birth was the baby checked for the first time by a health worker Number of days ...... or FCHV?

Don’t know ...... 98 (Write “00” if same day of birth) 1006 Who checked your newborn’s health at Doctor ...... 1 that time? Nurse/ANM ...... 2 HA/AHW ...... 3 Probe: Anybody else? FCHV ...... 4 Other (Specify)______...... 6 (CIRCLE ALL RESPONSES GIVEN) Don’t know / don’t remember ...... 98

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S.No. Question Codes Go To Note to interviewer: compare responses to 1003 - 1006 with the responses to 807-809 and confirm that any discrepancies between care provided to mother and newborn are accurate. 1007 Was your baby checked a second time by a Yes ...... 1 health professional or FCHV up to four No...... 2 1009 weeks after birth? 1008 Who checked on your newborn’s health Doctor ...... 1 the second time up to four weeks after Nurse/ANM ...... 2 birth? HA/AHW ...... 3 FCHW ...... 4 (CIRCLE ALL RESPONSES GIVEN) Other (Specify) ______.... 96 Don’t know / don’t remember ...... 98 1009 Did (NAME) receive a BCG vaccination Yes ...... 1 against tuberculosis, that is, an injection in No ...... 2 the right arm that usually causes a scar? Don't know ...... 98 1010 Did your newborn experience any of the following health problems at any time during the first two months following delivery? (Read out all responses one after another and Record all responses accordingly.) Yes No 1. Fever? 1 2 2. Feeding problem? 1 2 3. Fast breathing? 1 2 4. Chest-in-drawing/difficulty breathing? 1 2 5. Drowsy? 1 2 6. Convulsions? 1 2 7. Skin pustules? 1 2 If all=2 8. Skin around the cord red? 1 2 1018 9. Redness or discharge from the umbilicus? 1 2 10. Felt cold/hypothermia? 1 2 11. Nasal flaring? 1 2 12. Grunting? 1 2 13. Bulging fontanelle? 1 2 14. Discharge from the eyes? 1 2 1011 Where did you seek care for the problems Government Hospital ...... 1 you stated above? PHCC ...... 2 Urban health clinic ...... 3 Prompt: Anywhere else? Health post/sub-health post ...... 4 Community health unit ...... 5 (CIRCLE ALL RESPONSES GIVEN) PHC/ORC ...... 6 Private Hospital/Clinic/N. Home ...... 7 Pharmacy ...... 8 FCHV ...... 9 TBA ...... 10 Dhami / Jhankri ...... 11 Nowhere (treatment at home) ...... 12 Nowhere (did not seek treatment) ...... 13 Other (Specify) ______..... 96 1012 What type of treatment were you given? Oral medicine ...... 1 Injection...... 2 (CIRCLE ALL RESPONSES GIVEN) Ointment ...... 3 Other (Specify)______..... 96 Don’t know ...... 98

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S.No. Question Codes Go To Check Q1011, and circle below

1013 Sought care from a health facility (Q.No. 1011 = 1, 2, 3, 4, 5, 6 or 7) 1 Did not seek care from a health facility (Q.No. 1011 = 8, 9, 10, 11, 12, 13 or 96 ...... 2 1017 Only ask if 1012=2

1014 For how many days was an injectable Days ...... treatment given? Don't know ...... 98 1015 If care was sought from a health facility, was Yes ...... 1 1018 the child admitted? No...... 2 1016 I understand that your child was not admitted but that you visited a health facility. 1018 Times Please specify the number of times you visited the health facility. 1017 Why didn’t you seek care for any of your Not felt necessary ...... 1 child’s health problems from a health facility? No reliable service ...... 2 Financial problem ...... 3 Probe: Any other reasons? Health service not easily accessible ...... 4 Don't know where to go ...... 5 (CIRCLE ALL RESPONSES GIVEN) Don't have friend to go ...... 6 Others (Specify) ______...... 96 Don't know ...... 98 1018 Was your child weighed at any time after Yes ...... 1 birth? No ...... 2 1023 Don't know ...... 8 1019 When was your baby [NAME] weighed for Within 24 hours ...... 1 the first time after birth? 1-2 days ...... 2 3 days ...... 3 After 3 days ...... 4 Don’t know ...... 98 1020 Where was the baby weighed? Government Hospital ...... 1 PHCC ...... 2 Health post ...... 3 Pvt. Hospital/Clinic/N. Home ...... 4 Your home ...... 5 Other/FCHV home ...... 6 Other (Specify)______.... 96 1021 Who weighed the baby? Doctor ...... 1 Staff Nurse/ANM ...... 2 Paramedics ...... 3 FCHV ...... 4 Other (Specify)______.... 96 1022 How much did [NAME] weigh? 1. KG from recall ......

RECORD WEIGHT IN KILOGRAMS 2. KG from card ...... FROM HEALTH CARD, IF Don’t know ...... 98 AVAILABLE.

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S.No. Question Codes Go To 1023 When your child was born, was s/he very Very large...... 1 large, larger than average, average, smaller Larger than average ...... 2 1031 than average, or very small? Average ...... 3 Smaller than average ...... 4 Very small ...... 5 Unsure ...... 98 1031 1024 Because your baby was small, did you Yes ...... 1 receive extra visits from a health worker or No...... 2 FCHV? Don’t know ...... 8 1025 What advice did the health worker or FCHV Frequent breastfeeding...... 1 give when your baby [NAME] was smaller Keep baby warm ...... 2 than other babies? Keep baby against mother's body, skin to skin ...... 3 Probe: What other advice? Newborn danger signs ...... 4 Repeatedly weigh baby ...... 5 (CIRCLE ALL RESPONSES GIVEN) Repeated visit to health facility or health worker ...... 6 Other (Specify)______.... 96 Don’t know ...... 98 No advice ...... 0 1026 Because your baby was small, was [NAME] Yes ...... 1 referred to a health facility? No ...... 2 1029 1027 Did you take the baby to a health facility? Yes ...... 1 1029 No ...... 2 1028 Why didn't you take baby to a health facility? Not felt necessary ...... 1 (CIRCLE ALL RESPONSES GIVEN) No reliable service ...... 2 Financial problem ...... 3 Health service not easily accessible ...... 4 No one to assist ...... 5 No time ...... 6 Took care at home ...... 7 Cultural barrier ...... 8 Others (Specify) ______...... 96 Don't know ...... 98 1029 Because your baby was small, did you give Yes ...... 1 extra care to your baby? No ...... 2 1031 1030 What extra care did you give to your baby? More frequent breastfeeding ...... 1 Skin-to-skin care ...... 2 Fed by cup or spoon ...... 3 (CIRCLE ALL RESPONSES GIVEN) Don't remember/know ...... 98 Other (Specify)______.... 96 1031 Following your last delivery, did the health Yes ...... 1 worker or FCHV talk about "keeping the No ...... 2 baby in skin-to- skin contact with the mother?" 1032 Was the baby placed in skin-to-skin contact Not at all ...... 1 in the first 24 hours after delivery? A little (up to 2 hours total ...... 2 Moderate amount (between 2 to 5 hours total) ...... 3 A lot (more than 5 but less than 12 hours) ...... 4 Most of the time (day & night, more than 12 hours) ...... 5

123 Section 11: Postpartum Family Planning and Birth Spacing

Interviewer: “Now, I would like to talk about family planning – the various ways or methods that a couple can use to delay or avoid a pregnancy.” S.No. Question Codes Go To 1101 Did a health worker counsel you on birth Yes ...... 1 spacing or family planning at any time No ...... 2 following your most recent delivery? 1102 Have you done something or used any Yes ...... 1 method to delay or avoid getting pregnant at No ...... 2 End. any time after your most recent delivery? 1103 What was the first method you used after Female sterilization ...... 1 the delivery? Male sterilization ...... 2 Pill ...... 3 IUCD ...... 4 Depo-provera ...... 5 Implant (Norplant) ...... 6 Condom ...... 7 Periodic abstinence ...... 8 Withdrawal ...... 9 LAM ...... 10 Other (Specify)______..... 96 1104 After how many months of your most recent delivery did you first start to use a Months ...... family planning method?

Time interview ends: HH _ _ MM _ _ (24 hr.)

* End Interview. *

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