Newborn deaths and a vision for a post-pandemic Nepal

According to a recent journal article, it will be 2067 before newborn deaths among the poorest Nepalis have fallen enough to reach the global target set for 2030. That target, of 12 or fewer deaths per 1,000 live births, was attained by the wealthiest in Nepal four years ago, but the impact of COVID-19 may increase inequality and make it even more difficult for the country to reduce infant mortality.

If the pandemic shutdown is an opportunity to reimagine our societies, what should Nepal make of the widening gap in newborn deaths? Yes, overall trends are improving — both maternal and newborn health have made major gains in recent decades — but the poorest families are still lagging behind.

No society is free from inequality. Look at the US: the top 1 percent of families took home an average of 26 times as much income as the bottom 99 percent in 2015. In my home country of Canada, Indigenous people on average live 15 fewer years than others.

The study in the Maternal and Child Health Journal found that the mortality rate in Nepal of newborns (up to 28 days old) across all socioeconomic groups in 2001–2016 ‘shows significant disparities between different population groups, and that all these disparities either widened or remained constant over the 15-year period’.

A secondary analysis of data from the 2001, 2006, 2011 and 2016 Nepal Demographic and Health Surveys, the study added: ‘In 2016, women who had not received a tetanus vaccination had the highest risk of neonatal mortality, followed by women with no education. Other factors ... were giving birth before the age of 20, household air pollution, belonging to a poorest quintile, residing in a rural area, and having no toilet at home.’

The authors suggests that a multi-sectoral approach will be needed to improve the neonatal death rate (23 deaths per 1,000 live births in 2015) among all groups. Noting the current decentralisation of health care to provinces and local governments they add: ‘The engagement of the education, healthcare, water and sanitation sectors and of local communities and leaders for the development of their areas will go a long way to overcoming social determinant to neonatal health and survival.’

One thing the COVID-19 pandemic has revealed is how precariously most people live today, even in the ‘wealthy’ west. I was taught to always keep the equivalent of three months’ salary (or was it six months?) aside for a rainy day. That was 30 years ago. Today in places including Canada, and especially the US, being without work for a couple of weeks is devastating to many people, leaving them unable to pay their rent or mortgage, vehicle loans or credit card payments.

Among the poorest of the poor in Nepal, loss of work can quickly lead to families missing meals. As Bikash Gauchan of Achham’s Bayalpata Hosptial recently pointed out, if a coronavirus outbreak occurs in western Nepal it will not be an extraordinary burden for people, because poverty there means that they already shoulder a much heavier load than other Nepalis.

And that gap is growing. While remittances from Nepali workers abroad have helped reduce overall poverty, 10% of rich Nepalis now own property worth 26 times more than the 40% of the poorest. The Karnali government had spent only 11% of its annual development budget in the first 8 months of the current year. In a province that ranks lower than all the others by most indicators, how could leaders fail to spend money earmarked to improve life for their citizens? Even if their attempts failed, that would still be preferable to doing nothing.

In coming months as the pandemic subsides (at least its first wave) will the new New Nepal be content to resume cutting more trees, mining rivers, and clearing land to make way for new and bigger roads? Or can it instead seriously contemplate where it is headed and why many Nepalis are not included on the journey?

In terms of development indicators, and not just for newborn mortality, the easy work has been done. Population-wide measures like pre-natal checkups for pregnant women, deliveries in health facilities and getting help to treat pneumonia, are in place. What remains is to ensure that all Nepalis, including the least educated, most remote and the truly marginalised, receive the same treatment. This will take a larger, more focussed effort and above all, a consensus and determination that a 50-year gap between rich and poor is unacceptable.