Newborn & Postnatal (Sutkeri) Care in Nepal: Navi, PNC Visits, KMC

In Nepal, the first week of life is the riskiest period for a baby, so the Ministry of Health and Population (MoHP), through the Family Welfare Division (FWD, formerly the Family Health Division) and the Child Health Division of the Department of Health Services (DoHS), promotes a simple 'essential newborn care' package that every family can follow whether the birth happened at a health facility or at home. The package brings together thermal care (keeping the baby warm), clean cord care with chlorhexidine, early and exclusive breastfeeding, and timely postnatal check-ups. These steps are set out in the National Medical Standard for Maternal and Newborn Care (MoHP, 2020 AD / 2077 BS).

Immediately after birth the baby should be dried thoroughly, placed skin-to-skin on the mother's chest, and covered with a warm cloth including a cap, because newborns lose heat very quickly. Breastfeeding should begin within the first hour of life, and the baby should receive only breast milk (no honey, ghee, water, or animal milk) for the first six months. Bathing is delayed for at least 24 hours to avoid chilling the baby (hypothermia).

Why this matters is stark: Nepal's neonatal mortality rate was about 21 deaths per 1,000 live births in the Nepal Demographic and Health Survey (NDHS) 2022, and neonatal deaths make up roughly three-quarters of all infant deaths. About 15 percent of babies are born with low birth weight nationally. Most newborn deaths from infection, cold, and feeding problems are preventable with the simple home-care steps described in this guide.

The single most important cord-care message in Nepal is: apply 4% chlorhexidine gel or solution to the umbilical stump, and otherwise keep the cord clean and dry. The Government of Nepal approved 4% chlorhexidine (equivalent to 7.1% chlorhexidine digluconate) for umbilical cord care on 23 December 2011 (8 Poush 2068 BS), making Nepal one of the first countries in the world to adopt this life-saving antiseptic at national scale. The intervention is delivered through the Chlorhexidine Navi Care Program, and the product is widely known by the Nepali term 'Navi' (नाभी, the navel/cord).

The reason for the strong recommendation is the evidence: pooled analysis of community trials in South Asia, including landmark studies in Sarlahi, Nepal, showed that cleansing the newborn cord with 4% chlorhexidine reduces the risk of newborn death by about 23 percent and greatly lowers cord infection (omphalitis). Chlorhexidine is a broad-spectrum antiseptic that keeps working on the skin for many hours after a single application. Because of this residual effect, Nepal's national policy uses a single application soon after the cord is cut for facility births, while for home births in high-mortality settings the World Health Organization (WHO) supports once-daily application for the first week.

Practically, the antiseptic is applied by a birth attendant or trained health worker immediately after the cord is cut and tied, covering the tip and base of the stump. After that, the family should NOT apply anything else - no oil, ash, cow dung, turmeric, or traditional pastes - because these traditional practices introduce germs and cause dangerous cord infections. The cord should be left uncovered above the diaper line so it dries and falls off naturally, usually within one to two weeks. If the skin around the cord becomes red, swollen, foul-smelling, or oozes pus, the baby needs to be taken to a health facility.

Postnatal care (PNC) is the set of checks for the mother (sutkeri) and the newborn in the days after birth. Nepal's national protocol recommends at least three PNC contacts for every mother and baby regardless of where the delivery took place: the first within 24 hours of birth, the second on the third day, and the third on the seventh day of life. These early checks catch problems - bleeding and infection in the mother, and feeding difficulty, jaundice, cold, or infection in the baby - at the point when they are most likely and most treatable.

At each visit the health worker weighs the baby, checks its temperature and breathing, examines the cord, watches a breastfeed, looks for jaundice (yellow skin or eyes), and asks about danger signs. For the mother, they check bleeding, the uterus, blood pressure, any signs of infection or high blood pressure (pre-eclampsia), the perineum, and mood, and they support breastfeeding and family planning counselling. In many rural areas a Female Community Health Volunteer (FCHV) or an outreach worker conducts home-based visits, which is especially important for the large number of births that still take place at home.

Families should not wait for the seventh-day visit if something seems wrong: the schedule is a minimum, not a limit. A baby that will not feed, feels cold or hot, breathes fast or with difficulty, or becomes floppy or unresponsive needs urgent care immediately, whatever day it is. Mothers should also complete their own postnatal checks and take the iron-folic-acid and vitamin A supplements provided free at government facilities.

Kangaroo Mother Care (KMC) is continuous, direct skin-to-skin contact between the baby and the mother's (or another caregiver's) bare chest, combined with exclusive breastfeeding and close monitoring. It is Nepal's core intervention for low-birth-weight (LBW) and preterm babies because it keeps the baby warm using the mother's body heat, steadies breathing and heart rate, promotes breastfeeding, protects against infection, and reduces newborn deaths in small babies. WHO and Nepal's guidelines recommend KMC for babies weighing under about 2,000-2,500 grams and for those born preterm, once the baby is clinically stable, and increasingly it is started as early as possible after birth.

In practice the baby is placed upright between the mother's breasts, chest-to-chest and skin-to-skin, wearing only a nappy, a cap, and socks, and is then wrapped snugly against the mother with a cloth so only the face is exposed. The position should be maintained for as many hours a day as possible - ideally continuously, and at least several hours at a stretch - and the mother feeds on demand, using expressed breast milk if the baby is too small to suckle directly. Fathers and other family members can share KMC so the mother can rest.

KMC can be started in hospital in a KMC ward or after step-down from a Special Newborn Care Unit (SNCU/NICU), and it can be continued at home once the baby is feeding well and gaining weight. Nepal has expanded KMC through national KMC guidelines and hospital-based programmes with UNICEF and other partners. Families should continue KMC at home for small babies until the baby reaches about 2,500 grams or begins to resist the position, and they should keep attending PNC and growth-monitoring checks.

Every family should memorise the newborn danger signs used in Nepal's Integrated Management of Neonatal and Childhood Illness (IMNCI) approach, because a sick newborn can deteriorate within hours. If a baby shows any one of these signs, it must be taken to a health facility or hospital immediately, ideally after a first dose of care from a trained health worker. Do not wait, do not rely on home remedies, and keep the baby warm during transport.

The danger signs include: not feeding well or unable to feed at all; convulsions (fits); fast breathing (60 breaths per minute or more) or severe chest indrawing; the baby is unusually cold (hypothermia) or hot (fever); movement only when stimulated, or no movement at all (lethargy/unconsciousness); a red, swollen, or pus-discharging cord or skin; yellow palms and soles (deep jaundice); and persistent vomiting or a swollen, tense abdomen. Bleeding, a bulging soft spot, or blue/very pale colour are also emergencies.

Because these signs are easy to miss, Nepal's PNC home visits and FCHV counselling deliberately teach mothers and families to recognise them. Recognising 'not feeding' and 'lethargy' is especially important, as families tend to spot convulsions and chest indrawing but overlook feeding problems, which are often the first sign of serious infection (sepsis). When in doubt, treat it as an emergency.

Essential newborn services in Nepal are delivered free of charge through government health posts, primary health care centres, district and provincial hospitals, and community outreach. Chlorhexidine (Navi care), the vitamin A and iron-folic-acid supplements for mothers, immunisation, and PNC checks are all part of the free basic health service package, and the Aama Surakshya (Safe Motherhood) programme provides transport incentives and free delivery care to encourage facility births and follow-up.

Female Community Health Volunteers (FCHVs) are the frontline link for most families: they counsel mothers on breastfeeding, cord care, warmth, and danger signs, and they refer sick newborns. Every district has referral pathways to hospitals with Special Newborn Care Units (SNCUs) and KMC facilities for small or sick babies. Immunisation begins at birth or the first contact with BCG and hepatitis B / polio doses according to the national schedule.

For any emergency, families should go to the nearest birthing centre or hospital without delay and can call available local health post numbers or the health hotline for guidance. Keeping the mother-child health card (and recording each PNC visit, weight, and immunisation) helps health workers track the baby's progress and ensures nothing in the schedule is missed.