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Based on the study findings and the discussion and keeping the limitations in mind, the study highlights the following policy implications and recommendations.

• The women belonging to the fourth and the highest wealth quintiles had increased odds of demonstrating good newborn care practices. This finding reinforces that improving the economic status of families is important to improve the health behaviours and status. This is an important finding for programmers and policy makers as it provides direction to them in designing integrated programs, which include components that help to improve economic status together with improving health status.

• It is recommended that pregnant women should receive ANC from a SBA at least four times during their pregnancy under normal circumstances and their deliveries should be assisted by a SBA. In the study, the coverage of ANC and delivery from a SBA are unacceptably low. In Nepal, lack of access to SBA services and the unequal distribution of SBAs are the main reason for the low utilization of SBA services. Moreover, pregnant women might not know who the SBAs are in their community and might be unaware of the benefits of receiving ANC from them. Realising the important role of SBAs in reducing maternal and neonatal mortality and morbidity, the MoHP in 2006 formulated the national policy on SBA. In 2005, a maternity incentive scheme was already adopted to increase the demand for maternity services along with a focus on improving access to such services. In 2009, the Nepal government in a bid to meet the MDGs made delivery and management of obstetric complications free of cost in all public health facilities. The implementation and enforcement of those policies are essential to meet the MDGs related to maternal and child health. Therefore, it is important for safe motherhood and newborn health that programmers monitor its implementation. An audit of service delivery areas and research is recommended to understand why SBA services are unacceptably low even after several policy initiatives have been implemented.

• The results of the study confirmed that correct maternal knowledge of good newborn care practices has a positive impact on those practices. In rural Nepal,

immediate newborn care practices such as cord cutting, bathing baby, and helping mothers in putting baby to the breast are usually performed by the person assisting during the delivery. Therefore, good newborn care practices also depend on the knowledge of person assisting the delivery. In rural Nepal, the vast majority of the deliveries occur at home, and are mostly assisted by TBAs and elderly females, instead of a SBA. Therefore, one important approach for programmers to improve the newborn care practices in the rural areas is to include TBAs and elderly household females in their training programs to increase their knowledge.

• About half of the sample women did not meet FCHVs during their pregnancy. In addition, more than three-quarters of the women who met FCHVs during their pregnancy reported being not counselled on specific newborn care issues. These findings reflect the lack of access to FCHV services and the low efficiency of the FCHVs in educating all the pregnant women they visit in the communities of Nepal. The role of FCHVs in educating pregnant women and mothers on family planning, safe motherhood and child health and distribution of family planning and child health commodities is considered important in the rural areas of Nepal where access to health facilities is difficult or limited. Nepal has nearly 50,000 FCHVs in its 75 districts. FCHVs are volunteers and most of the public health programs of Nepal are dependent upon them to deliver the services at grassroots levels. The MoHP of Nepal has provided various basic and refresher training to FCHVs from time to time to refresh and upgrade their knowledge and skills. Local governments have also made attempts to support FCHVs in several ways. Yet, the supports are not adequate and more needs to be done to keep up the spirit of voluntarism among those cadres of health workers. The reproductive health programmers need to understand the reasons the FCHV are not able to reach all the pregnant women of their catchment area, so as to improve the health status of pregnant women, mothers and newborns. If FCHVs’ are to provide good service they need to be motivated to find women and mothers in need and the families also need to understand and expect their role.

• Cultural factors have been important in interpreting the results of this study. For instance, bathing the newborn soon after birth was perceived important to ‘purify’ the baby. Prelacteal feeds were given to the baby as the first feed instead of colostrum because colostrum was perceived as ‘dirty’ and not good for the baby.

Cultural reasons are probably hard to modify in practice. Programmers should be able to distinguish which of the factors are easily modifiable and which are not. Improving the economic status of families and increasing their knowledge are the factors that are likely to be changed with less effort than the cultural beliefs. Therefore, it is recommended that programmes should prioritize which factors are to be addressed in the short term and which in the long term for the better health of newborn babies.