Sight and Life Magazine 1/2011

32 THE FEASIBILITY OF DELIVERING VITAMIN A TO NEWBORNSFigure 2: Map of NVAS pilot districts in NepalNVAS pilot districtsFar-WesternRegionBankeIndiaMid-WesternRegion0 20 60 100 KilometersWestern RegionNawalparasiTanahuCentral RegionFCHV dosing modelMother dosing modelSindhuliEastern Regionrecommendation: “Operational research on how to reach mostbabies in developing countries within two days of birth shouldbe conducted in general, not necessarily in the context of neonatalvitamin A supplementation.” The consultation also revieweda systematic review of neonatal vitamin A trials. 25 It concludedthat insufficient evidence existed to recommend a global policyof supplementing newborns with vitamin A until further efficacytrials in appropriate populations are conducted in Africa andAsia. WHO is currently supporting additional efficacy studies inAfrica (Tanzania and Ghana) and South Asia (India), as well asstudies investigating potential biological mechanisms throughwhich NVAS may decrease the risk of early infant mortality.Program implicationsAdequate and effective NVAS will require innovative but feasibleprograms in South Asian settings, where often >80% of infantsare born at home. For example, newborn dosing might requireidentifying and engaging neighborhood “watch” networks todetect births and rapidly dose infants, or using cell phones tocontact health workers at the time of birth. The capsule wouldneed to be widely available, perhaps through both the privateand public sectors. It could be included as a new component in“safe birthing kits” for women to use themselves (obtained duringantenatal care or purchased in local shops), provided at thetime of home-delivery by nurse midwives or trained traditionalbirth attendants or, lastly, at clinic- or hospital-based obstetriccare and delivery programs. Newborn VA delivery could be combinedwith other emerging and effective neonatal care services,such as cord cleaning with chlorahexadine wipes 26 and newborncare intervention packages. 27 It could provide an opportunityto establish birth dates and set the timing for an infant’s “sixmonth”VA-dosing visit – an idea that is currently gaining interest.Alternatively, in contexts where a high proportion of womenattend antenatal clinics, women could be given the supplementand instructed on its use and administration, and then give itdirectly to their newborn shortly after birth.NVAS feasibility activities purposeIn both Nepal and Bangladesh, NVAS feasibility activities wereto identify, develop, and evaluate feasible models for deliveringNVAS integrated within existing ante- and postnatal interventionsat a scalable level within existing delivery platforms andgovernment health services.NepalBackground. Nepal is on track to meet its Millennium DevelopmentGoal (MDG)-4 to reduce under-five mortality by two-thirds;however, the government is finding ways to make further reductionsby seeking efficacious interventions that reduce neonataland early infant deaths. The Child Health Division, Departmentof Health Services of the Nepal Ministry of Health and Populationformulated a policy to pilot first, and piloted NVAS in 2009in four districts (Figure 2), in partnership with the USAID-fundedNepal Family Health Program-II (NFHP-II), UNICEF, and theMicronutrient Initiative (MI).Delivery models. Considering that ~80% of births in Nepaloccur in the home, the extensive network of female communityhealth volunteers (FCHVs), and the government’s effortsto intensify and improve access to Antenatal Care services,Nepal selected two distribution models for feasibility testing:1. The “FCHV Dosing” model, using postnatal home visits byfemale community health volunteers to administer vitamin Adirectly to newborns in two districts (Banke and Nawalparasi)(Figure 3); and2. The “Mother / Family Member Dosing” model, in which motherswho attend an antenatal clinic at a health facility (HF), or arevisited at home by the FCHV after the eighth month of pregnancy,are counseled about NVAS and given a supplement which theygive directly to their newborn, also in two districts (Sindhuli andTanahu) (Figure 4).Monitoring and evaluation. NVAS implementation is beingmonitored through the routine government health managementand information system. To record information on NVASreceipt, the existing Iron Intensification Register, a record usedto track iron and folic acid tablet receipt among pregnant andpostpartum mothers, was modified. Data from this record arecompiled and sent monthly to the district and national levels.In addition, three to four external monitors per district provide