Infant death rates and animal-shed delivery in remote rural areas of Nepal

This article outlines a community-based retrospective study in a remote area of Nepal and describes local birth practices and their impact on infant mortality. Data collection was carried out in two steps, a household survey from September to October 1996 and a qualitative research phase. Data collected include socio-economic background, reproductive history, birth practices and child survival. Among 3007 live-born children, 660 (22%) died before their first birthday. In keeping with local customs, approximately half of the children were delivered in an animal shed and the other half in the home. Children born in an animal shed were at significantly higher risk of dying than were those born in the home even after adjusting for socio-economic status and biological variables. The association was stronger in the neonatal period (OR = 2.8, 95% CI 1.9-4.1) than during the post-neonatal period (OR= 1.3, 95% CI 1.02-1.6). The preparation of the delivery place was inadequate and thereby facilitated infection of both the newborn and the mother. Traditional norms and animal-shed delivery practices are common in the Jumla community. The reasons addressed for giving birth in the animal shed included (1) Household Deity's anger if delivery takes place in the home and (2) easy to clean the shed following the birth.     

Twinning rates in Tamilnadu.

A prospective study of human reproduction was conducted in Tamilnadu State, South India, from 1969 to 1975. This paper reports twinning rates and relates these to maternal age, parity, and consanguinity. Birth weights and other dimensions at birth and infant mortality are also studied. The overall twinning rate was 1 in 115 births. Dizygotic twinning rates increased significantly with maternal age and parity. The measurements at birth for like-sexed twin pairs were lower than that of unlike-sexed, but the mortalities did not differ significantly. Twins, in general, had a several fold increase in mortality as compared with singletons.     

Twinning rates by residence in Denmark 1978 to 1982

It has been suggested in the literature that twinning rates are reduced by psychosocial stress associated with urban life. No support for this hypothesis was found in a study based upon the 5,762 twins and 280,158 singletons that were born in Denmark in the period 1978 to 1982.     

Risk of death following pregnancy in rural Nepal

OBJECTIVE: To investigate the length of time following pregnancy during which the risk of mortality was elevated among women in rural Nepal. METHODS: An analysis was performed of prospective data on women participating in the control group of a large, population-based trial. Weekly visits were made for three years to 14805 women aged 14-45 years. Pregnancy and vital status were assessed. A total of 7325 pregnancies were followed. Mortality during and following pregnancy, expressed on a person-time basis, was compared to referent mortality unrelated to pregnancy (52 weeks after pregnancy) in the same cohort. FINDINGS: The relative risk (RR) of death during pregnancy but before the onset of labour was 0.93 (95% confidence interval (CI): 0.38-2.32). During the perinatal period, defined as lasting from the onset of labour until seven days after outcome, the RR of death was 37.02 (95% CI: 15.03-90.92). The RR for 2 to 6 weeks, 7 to 12 weeks, and 13 to 52 weeks after pregnancy were 4.82, 2.59 and 1.01 with 95% CI of 1.77-13.07, 0.81-8.26 and 0.40-2.53, respectively. The RR of death was 2.21 (95% CI. 1.03-4.71) during the conventional maternal mortality period (pregnancy until 6 weeks after outcome). It was 2.26 (95% CI: 1.05-4.90) when the period was extended to 12 weeks after pregnancy outcome. CONCLUSION: The risk of mortality associated with pregnancy should be assessed over the first 12 weeks following outcome instead of over the first 6 weeks.     

Socio-cultural factors influencing adolescent pregnancy in rural Nepal

Early child bearing is a widely observed phenomenon in Nepal. However, little information is available in regard to its contributing factors. This retrospective exploratory study was carried out to determine factors contributing to adolescent pregnancy in rural Nepal. Cluster sampling technique was used to select the study settings. The findings on variable contributing to pregnancy from the sample of 575 mothers, who had their first pregnancy at an age below 19 years, were compared with the findings from an equal number of mothers who had their first pregnancy at the age of 20 years or above. The adolescent mothers were married at a comparatively younger age with a mean age of 15.9 years. Parents or elders, with/without the girl's consent, decided the majority of adolescent marriages. The age at marriage exposed women to early pregnancy regardless of who decided the marriage. Comparatively, most adolescent mothers were from a low social class, engaged in agricultural work, and they had low literacy rate. Majorities of the mothers from both groups had no prior knowledge about conception until they conceived. Peers were the main source of information regarding conception. Although the majority of the respondents knew at least one method of contraception, less than 1% had used it before their first pregnancy. To conclude, early pregnancy had put the adolescent mothers at the risk of unwanted pregnancy and obstetric complications. Women empowerment through compulsory girls' education would be the most effective strategy to prepare them for late marriage, planned and delayed pregnancy, and better motherhood.     

Children's health and play in rural Nepal

A study of morbidity and mortality in a peasant village in Nepal describes chronic malnutrition and endemic infectious disease. More than one-third of village children between the ages of 1 and 5 die. Those who survive apparently pursue a spontaneous strategy of maximizing their physical growth potential by minimizing the expenditure of energy in play. This raises the possibility that psychological, social and motor development is impaired. It is found, however, that while less time and energy is devoted to play, the pattern of play that does occur is similar to that of healthier peasant children in other times and places. It is therefore probable that maturational levels of attainment are not impaired, but it is urgent that this assumption be further investigated.     

A staff support programme for rural hospitals in Nepal

ProblemDistrict hospitals in Nepal struggle to provide essential services such as caesarean sections.ApproachRetention of health workers is critical to the delivery of long-term, quality health-care services. To promote retention and enhance performance in rural public hospitals, the Government of Nepal and the Nick Simons Institute progressively implemented a rural staff support programme in remote hospitals. After competitive selection for a compulsory-service scholarship and training, family practice doctors who could do basic surgery, orthopaedics and obstetrics were hired under a binding three-year contract in each participating hospital. Comfortable living quarters and an Internet connection were provided for the resident doctors; in-service training for all staff and capacity development for each hospital’s management committee were provided.

Local setting

Nepal’s mountainous landscape, poverty and inequitable rural/urban distribution of health workers pose barriers to adequate health care.

Relevant changes

Between 2011 and 2015 family practice doctors were maintained in all seven programme hospitals. All hospitals became providers of comprehensive emergency obstetric care and served more patients. Compared with hospitals not within the programme, deliveries increased significantly (203% versus 71% increase, respectively; P = 0.002). The programme recently expanded to 14 hospitals.

Lessons learnt

A package of human resource supports can improve the retention of doctors and the use of remote hospitals. Factors contributing to the success of this programme were compulsory-service scholarship, central personnel management, performance-based incentives and the provision of comfortable living quarters.     

Assessment of villagers' perceptions towards nutrition communication in rural Nepal

This article examines the perceptions of villagers of Nepal towards effective modes of nutrition communication affecting their nutritional health. Based on the villagers' experience of the nutrition communication used in various vitamin A projects surveyed in three districts of Nepal, a majority of the villagers strongly believe that a nutrition project cannot be effective in achieving its goals unless the local villagers are consulted during the process (defined to include design, development, implementation, and evaluation). They also believed that, among other modes of communication, a group discussion might be very effective in village nutrition communication. Similarly, based on the survey data analysis, it was found that the use of multiple media had a strong positive impact on the villagers' familiarity with and participation in the vitamin A projects surveyed. However, there was not any indication that such impact had a significant positive relationship with the reported level of knowledge of food items promoted by the vitamin A projects. Likewise, there was no suggestion of any strong relationship between the reported level of knowledge and the intake of food items promoted by the projects surveyed.     

Assessment of villagers' perceptions towards nutrition communication in rural Nepal

This article examines the perceptions of villagers of Nepal towards effective modes of nutrition communication affecting their nutritional health. Based on the villagers' experience of the nutrition communication used in various vitamin A projects surveyed in three districts of Nepal, a majority of the villagers strongly believe that a nutrition project cannot be effective in achieving its goals unless the local villagers are consulted during the process (defined to include design, development, implementation, and evaluation). They also believed that, among other modes of communication, a group discussion might be very effective in village nutrition communication. Similarly, based on the survey data analysis, it was found that the use of multiple media had a strong positive impact on the villagers' familiarity with and participation in the vitamin A projects surveyed. However, there was not any indication that such impact had a significant positive relationship with the reported level of knowledge of food items promoted by the vitamin A projects. Likewise, there was no suggestion of any strong relationship between the reported level of knowledge and the intake of food items promoted by the projects surveyed.     

Education and infant survival in rural Bangladesh

This paper explores the mechanism through which socioeconomic status affects infant deaths. The data used here come from a prospective study in rural Bangladesh. Both neonatal deaths and postneonatal deaths were found to be higher in number among those whose mothers have no schooling. Again, education of the mother has been found to be related to gestational month at termination and this gestational month at termination (which is the maturity of the newborn) determines the neonatal death. The other factors affecting infant mortality were the height of the mother and the weight of the infant. The taller the mother, the fewer the neonatal and post-natal deaths. The weight of the infant has a direct relationship to its survival during infancy.     

Newborn survival in Nepal: a decade of change and future implications

Nepal is on target to meet the Millennium Development Goals for maternal and child health despite high levels of poverty, poor infrastructure, difficult terrain and recent conflict. Each year, nearly 35,000 Nepali children die before their fifth birthday, with almost two-thirds of these deaths occurring in the first month of life, the neonatal period. As part of a multi-country analysis, we examined changes for newborn survival between 2000 and 2010 in terms of mortality, coverage and health system indicators as well as national and donor funding. Over the decade, Nepal's neonatal mortality rate reduced by 3.6% per year, which is faster than the regional average (2.0%) but slower than national annual progress for mortality of children aged 1-59 months (7.7%) and maternal mortality (7.5%). A dramatic reduction in the total fertility rate, improvements in female education and increasing change in skilled birth attendance, as well as increased coverage of community-based child health interventions, are likely to have contributed to these mortality declines. Political commitment and support for newborn survival has been generated through strategic use of global and national data and effective partnerships using primarily a selective newborn-focused approach for advocacy and planning. Nepal was the first low-income country to have a national newborn strategy, influencing similar strategies in other countries. The Community-Based Newborn Care Package is delivered through the nationally available Female Community Health Volunteers and was piloted in 10 of 75 districts, with plans to increase to 35 districts in mid-2013. Innovation and scale up, especially of community-based packages, and public health interventions and commodities appear to move relatively rapidly in Nepal compared with some other countries. Much remains to be done to achieve high rates of effective coverage of community care, and especially to improve the quality of facility-based care given the rapid shift to births in facilities.     

Expansion of rural health care and the use of maternal services in Nepal

In order to improve living standards among the rural poor, the government of Nepal has invested heavily in improving the provision of health care services in rural areas. The purpose of this paper is to assess the impact of this investment on the use of maternal health care services. A bivariate probit model is used to estimate the effect of physical access to government health care services, along with individual-, household-, and other location-specific characteristics, on the use of prenatal care and birth delivery care. The results of the estimation are used to carry out policy simulations that assess the magnitude of the impact of improvements in health care availability on service utilization. The results indicate that physical access to a health care facility, as it is currently structured in rural areas, has a statistically significant but modest impact on the use of maternal services.     

Retention of general practitioners in rural Nepal: a qualitative study

Objectives:  To explore the key issues that influence GP retention in rural areas of Nepal.
Design:  A qualitative study using triangulation of data from one postal questionnaire, one hand-delivered questionnaire with semistructured interview and focus group discussions. Data from a small community survey from 13 rural districts also included.
Participants:  Sixty-two Nepali GPs, 25 doctors in General Practice training programs, 11 individuals involved in policy development and rural health care.
Results:  The key issues identified by this study as critical to the retention of Nepali GPs in rural areas were:
•  Career/promotion prospects
•  Status/recognition
•  Financial incentives
•  Working conditions
•  Education for children
•  Continuing medical education
•  Political stability and security
Conclusions:  The strongest theme was that of career development. This must be addressed by the Government of Nepal if there is to be any hope of improving retention of GPs in rural areas. GPs need to have a clear career ladder, with recognition of the value of service in rural areas. There is, however, no one single answer to the complex interacting factors that impact on GP retention in rural Nepal. A multifaceted, holistic response is necessary. From the level of community awareness, a career structure and financial remuneration to adequately set up hospitals, functional teams, family support, continuing professional development and a secure working environment – each area must be addressed for the whole to function.     

Mortality rates in rural and urban areas of Brittany

Relative differences in environment, behaviour, social composition as well as access to health care tend to suggest that levels of health may vary between urban and rural areas. The aim of this study was to identify rural-urban variations in mortality risks in the region of Brittany for the period from 1988 to 1992. The definition of urban and rural areas used adhered to that of the zoning of urban areas established by the INSEE (the National Statistical Office). The amalgamation of all causes of standardised mortality ratios (SMR) show only a moderately increased risk in the rural areas compared with the overall regional level (+4% in men, +5-7% in women). The analysis of cause specific SMRs display higher rural mortality for cardiovascular diseases and external causes of death, road traffic accidents in particular (+24% in men). Among all specific causes investigated, only lung cancer mortality risk appears to be higher in urban areas.