Coverage of the WHO's four essential elements of newborn care and their association with neonatal survival in southern Nepal

Emily Bryce, Luke C. Mullany, Subarna Khatry, James M. Tielsch, Steven C. Leclerq, Joanne Katz

Research output: Contribution to journalArticlepeer-review


Background: Despite recent improvements in child survival, neonatal mortality continues to decline at a slower rate and now represents 47% of under-five deaths globally. The World Health Organization developed core indicators to better monitor the quality of maternal and newborn health services. One such indicator for newborn health is "the proportion of newborns who received all four elements of essential care". The four elements are immediate and thorough drying, skin to skin contact, delayed cord clamping, and early initiation of breastfeeding. Although there is existing evidence demonstrating an association with decreased neonatal mortality for each element individually, the cumulative impact has not yet been examined. Methods: This analysis uses data from a randomized trial to examine the impact of sunflower versus mustard seed oil massage on neonatal mortality and morbidity in the Sarlahi district in Southern Nepal from 2010 to 2017. The proportion of newborn infants receiving an intervention was the exposure and neonatal mortality was the outcome in this analysis. Neonatal mortality was defined as a death between three hours and less than 28 days of age. Associations between neonatal mortality and the essential elements were estimated by Cox proportion hazards models. The hazard ratios and corresponding 95% confidence intervals were reported. Results: 28,121 mother-infant pairs and 753 neonatal deaths were included. The percent receiving the individual elements ranged from 19.5% (skin to skin contact) to 68.2% (delayed cord clamping). The majority of infants received one or two of the elements of essential care, with less than 1% receiving all four. Skin to skin contact and early initiation of breastfeeding were associated with lower risk of neonatal mortality (aHR = 0.64 [0.51, 0.81] and aHR = 0.72 [0.60, 0.87], respectively). The risk of mortality declined as the number of elements received increased; receipt of one element compared to zero was associated with a nearly 50% reduction in risk of mortality and receipt of all four elements resulted in a 72% decrease in risk of mortality. Conclusions: The receipt of one or more of the four essential elements of newborn care was associated with improved neonatal survival. The more elements of care received, the more survival improved.

Original languageEnglish (US)
Article number540
JournalBMC pregnancy and childbirth
Issue number1
StatePublished - Sep 16 2020
Externally publishedYes


  • Cord clamping
  • Early initiation of breastfeeding
  • Immediate drying
  • Neonatal mortality
  • Skin to skin contact

ASJC Scopus subject areas

  • Obstetrics and Gynecology


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