# Impact of reduced institutional delivery coverage on neonatal survival during the peak of coronavirus disease 2019 pandemic in Nepal: Estimates using Lives Saved Tool model

## TL;DR

The study estimates how decreased institutional deliveries during Nepal's pandemic lockdown worsened neonatal survival, using a modeling tool.

## Contribution

The novelty is using the Lives Saved Tool to estimate pandemic-related neonatal mortality changes in Nepal based on institutional delivery coverage shifts.

## Key findings

- Neonatal mortality rates increased during Nepal's peak pandemic period due to reduced institutional deliveries.
- In 2021–2022, increased institutional deliveries led to higher neonatal lives saved compared to targets.
- Key interventions like resuscitation and cord care were most impactful for neonatal survival.

## Abstract

An alarming observation from high-volume obstetric facilities in Nepal indicating a decreased institutional delivery rate and increased institutional neonatal mortality rate after the initial nationwide lockdown signaled the adverse population-level impact of the pandemic on the national trajectory of neonatal survival.

We aimed to estimate the impact of change in institutional delivery coverage on cause-specific neonatal mortality during the coronavirus disease 2019 pandemic in Nepal.

Modeling-based study.

We used the open-access Lives Saved Tool, based on a linear deterministic mathematical model validated for estimating cause-specific neonatal mortality in low- and middle-income countries, to estimate the number of additional neonatal lives saved and neonatal mortality rates. Using coverage change in institutional delivery rates as a proxy for interventions during childbirth, we compared the estimates using ‘reported’ coverage change during the pandemic with the ‘targets’ per Nepal Every Newborn Action Plan.

The projected number of additional neonatal lives saved when the pandemic hit the hardest (Nepalese fiscal year 2020–2021) when national annual institutional delivery rate reportedly decreased was lower (104; 95% confidence interval: 69–148) compared to the target scenario (222; 95% confidence interval: 152–313). However, in the next year 2021–2022 when the institutional delivery rate increased, the number was higher (926; 95% confidence interval: 643–1295) compared to target scenario (329; 95% confidence interval: 226–466). The trajectory of the projected neonatal mortality rate per 1000 live births reversed (increased to 20.18) in 2020–2021 compared to 20.11 in 2019–2020 and then tracked down to 18.75 in 2021–2022. Most newborn lives would be saved from asphyxia, sepsis, and prematurity-related complications. Neonatal resuscitation, thermal protection, and cord care are the top three lifesaving interventions during childbirth.

Neonatal survival in Nepal was adversely impacted during the peak of the coronavirus disease 2019 pandemic, with a favorable bounce back next year, based on the Lives Saved Tool projection per change in institutional delivery coverage.

Projections From the Lives Saved Tool Model Based on the Change in Coverage of Institutional Childbirth Suggest an Adverse Impact on Neonatal Survival During the Peak of the Coronavirus Disease 2019 Pandemic in Nepal

The utilization of routine maternal, newborn, and child health services in low- and middle-income countries including Nepal was adversely but variably affected by the coronavirus disease 2019 pandemic. An alarming observation reported from an increase in the deaths of newborn babies with a decrease in the number of deliveries occurring in maternity hospitals in the beginning of the pandemic in Nepal signaled concern with uncertainty in the extent of negative impact on neonatal survival at the level of the population through the course of the pandemic. The researchers utilized the validated and open-access Lives Saved Tool to estimate the number of additional newborn lives that could be potentially saved from routine and basic interventions during childbirth when the coverage rates of institutional delivery changed during the pandemic in Nepal. Compared to the projection based on the scenario of meeting target coverage rates, the projected number of additional newborn lives saved was lower in the Nepalese fiscal year 2020–2021 based on the scenario of reported decrease in the annual rate of institutional delivery, which recovered favorably in the next year. The projected neonatal mortality rate also increased in that year (2020–2021) worst hit by the pandemic, instead of following the decremental trend before and after. These findings noted in the face of a global public health emergency call for a resilient and sustainable national and global health policy and programming for maternal and newborn health.