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BACKGROUND: Globally, many mothers and their babies die during pregnancy and childbirth. A key element of optimizing outcomes is high- quality antenatal care. The Government of Nepal has significantly improved antenatal care and health outcomes through high-level commitment and investment; however, only 69% of patients attend the 4 recommended antenatal appointments.OBJECTIVE: This study aimed to evaluate the quality and perceptions of antenatal care in Nepal to understand compliance with the Nepalese standards.STUDY DESIGN: This cross-sectional study was conducted at a tertiary referral and private hospital in Kathmandu and a secondary hos- pital in Makwanpur, Nepal. The study recruited 538 female inpatients on postnatal wards during the 2-week data collection period from May 2019 to June 2019. A review of case notes and verbal survey of women to understand the pregnancy information they received and their sat- isfaction with antenatal care were performed. We created a summary score of the completeness of antenatal care services received ranging from 0 to 50 (50 indicating complete conformity with standards) and investigated the determinants of attending 4 antenatal care visits and patient satisfaction.RESULTS: The median antenatal care attendance was 4 visits at the secondary and referral hospitals and 8 visits at the private hospital. However, 24% of the patients attended CONCLUSION: Few women achieved full compliance with the Nepali antenatal care standards; however, some services were delivered well. To improve, each antenatal contact needs to meet its clinical aims and be respectful. To achieve this communication and counseling training for staff, investment in health promotion and delivery of core services are needed. It is important that these interventions address key issues, such as attendance in the first trimester of pregnancy, improving privacy and optimizing communication around danger signs. However, they must be designed alongside staff and service users and their efficacy tested before widespread investment or implementation.

Objective:To model the potential impact and equity impact of fortifying rice on nutritional adequacy of different subpopulations in Nepal.Design:Using 24-h dietary recall data and a household consumption survey, we estimated: rice intakes; probability of adequacy (PA) of eight micronutrients commonly fortified in rice (vitamin A, niacin (B3), pyridoxine (B6), cobalamin (B12), thiamin (B1), folate (B9), Fe and Zn) plus riboflavin (B2), vitamin C and Ca and mean probability of adequacy (MPA) of these micronutrients. We modelled: no fortification; fortification of purchased rice, averaged across all households and in rice-buying households only. We compared adequacy increases between population subgroups.Setting:(i) Dhanusha and Mahottari districts of Nepal (24-h recall) and (ii) all agro-ecological zones of Nepal (consumption data).Participants:(i) Pregnant women (n 128), mothers-in-law and male household heads; (ii) households (n 4360).Results:Unfortified diets were especially inadequate in vitamins B12, A, B9, Zn and Fe. Fortification of purchased rice in rice-purchasing households increased PA > 0·9 for thiamin, niacin, B6, folate and Zn, but B12 and Fe remained inadequate even after fortification (PA range 0·3–0·9). Pregnant women’s increases exceeded men’s for thiamin, niacin, B6, folate and MPA; men had larger gains in vitamin A, B12 and Zn. Adequacy improved more in the hills (coefficient 0·08 (95 % CI 0·05, 0·10)) and mountains (coefficient 0·07 (95 % CI 0·01, 0·14)) but less in rural areas (coefficient −0·05 (95 % CI −0·09, −0·01)).Conclusions:Consumption of purchased fortified rice improves adequacy and gender equity of nutrient intake, especially in non-rice-growing areas.

Background: Maternal and neonatal mortality rates remain high in many less economically developed countries, including Nepal. Good quality antenatal care can reduce adverse pregnancy outcomes; however, identifying how best to improve antenatal care can be challenging. Objectives: Our objective was to identify interventions for maternal or neonatal benefit that have been investigated in in the antenatal period in Nepal. We wanted to understand their scale, location, cost, and effectiveness. Study design: Online bibliographic databases (Cochrane Central, Medline, Embase, CINAHL Plus, British Nursing Index, PsycInfo, Allied and Complementary Medicine) and trial registries (ClinicalTrials.gov and the World Health Organization Clinical Trials Registry Platform) were searched from their inception until 24th May 2020. We included all studies reporting any maternal or neonatal outcome following an intervention in the antenatal period. We screened studies and extracted data in duplicate. Meta-analysis was not possible due to the heterogeneity of interventions and outcomes, so we performed a narrative synthesis of the included studies. Results: Twenty-five studies met our inclusion criteria. These studies showed a variety of approaches to improving antenatal care (e.g. educational programs, incentive schemes, micronutrient supplementation) in different settings (home, community or hospital-based) and with a wide variety of outcomes. Less than a quarter of the studies were randomized controlled trials, and many were single-site or reported only short-term outcomes. All studies reported having made a positive impact on antenatal care in some way but only three provided a cost-benefit analysis to support implementation. None of these studies focused on the most remote communities in Nepal. Conclusions: Our systematic review found good quality evidence that micronutrient supplementation and educational interventions can bring important clinical benefits. Iron folic acid supplementation significantly reduces neonatal mortality and maternal anaemia, while birth preparedness classes increase uptake of antenatal and postnatal care, increase compliance with micronutrient supplementation, and increase awareness of danger signs in pregnancy. Funding: Project funding through University of Bristol Global Challenges Research Fund (GCRF) and salary support from National Institute for Health and Research (NIHR).

Funder: National Institute for Health Research; Id: http://dx.doi.org/10.13039/501100000272, OBJECTIVES: Preterm delivery (

Objective:To provide a comprehensive seasonal analysis of pregnant mothers’ eating behaviour and maternal/newborn nutritional status in an undernourished population from lowland rural Nepal, where weather patterns, agricultural labour, food availability and disease prevalence vary seasonally.Design:Secondary analysis of cluster-randomised Low Birth Weight South Asia Trial data, applying cosinor analysis to predict seasonal patterns.Outcomes:Maternal mid-upper arm circumference (MUAC), BMI, dietary diversity, meals per day, eating down and food aversion in pregnancy (≥31 weeks’ gestation) and neonatal z-scores of length-for-age (LAZ), weight-for-age (WAZ) and head circumference-for-age (HCAZ) and weight-for-length (WLZ).Setting:Rural areas of Dhanusha and Mahottari districts in plains of Nepal.Participants:2831 mothers aged 13–50 and 3330 neonates.Results:We found seasonal patterns in newborn anthropometry and pregnant mothers’ anthropometry, meal frequency, dietary diversity, food aversion and eating down. Seasonality in intake varied by food group. Offspring anthropometry broadly tracked mothers’. Annual amplitudes in mothers’ MUAC and BMI were 0·27 kg/m2 and 0·22 cm, with peaks post-harvest and nadirs in October when food insecurity peaked. Annual LAZ, WAZ and WLZ amplitudes were 0·125, 0·159 and 0·411 z-scores, respectively. Neonates were the shortest but least thin (higher WLZ) in winter (December/January). In the hot season, WLZ was the lowest (May/June) while LAZ was the highest (March and August). HCAZ did not vary significantly. Food aversion and eating down peaked pre-monsoon (April/May).Conclusions:Our analyses revealed complex seasonal patterns in maternal nutrition and neonatal size. Seasonality should be accounted for when designing and evaluating public heath nutrition interventions.

Funder: NIHR Biomedical Research Centre funding scheme, Objective: On average, boys grow faster than girls in early life but appear more susceptible to undernutrition. We investigated sex differences in early child growth, and whether maternal nutritional status and diet differed by offspring sex during and after pregnancy in an undernourished population. Methods: We analyzed longitudinal data from a cluster‐randomized trial from plains Nepal, stratifying results by child or gestational age. Children's outcomes (0–20 months) were weight, length, and head circumference and their z‐scores relative to WHO reference data in 2‐monthly intervals (n range: 24837 to 25 946). Maternal outcomes were mid‐upper arm circumference (MUAC), and body mass index (BMI) during pregnancy (12–40 weeks) (n = 5550 and n = 5519) and postpartum (n = 15 710 and n = 15 356), and diet in pregnancy. We fitted unadjusted and adjusted mixed‐effects linear and logistic regression models comparing boys with girls. Results: Boys were larger than girls, however relative to their sex‐specific reference they had lower length and head circumference z‐scores from birth to 12 months, but higher weight‐for‐length z‐scores from 0 to 6 months. Mothers of sons had higher MUAC and BMI around 36 weeks gestation but no other differences in pregnancy diets or pregnancy/postpartum maternal anthropometry were detected. Larger sex differences in children's size in the food supplementation study arm suggest that food restriction in pregnancy may limit fetal growth of boys more than girls. Conclusions: Generally, mothers' anthropometry and dietary intake do not differ according to offspring sex. As boys are consistently larger, we expect that poor maternal nutritional status may compromise their growth more than girls. Copyright © 2021 John Wiley & Sons, Ltd.

ObjectivesTo identify delays and associated factors for maternal deaths in Nepal.DesignA cross-sectional case series study of maternal deaths. An integrated verbal and social autopsy tool was used to collect quantitative and qualitative information regarding three delays. We recorded death accounts and conducted social autopsy by means of community Focus Group Discussions for each maternal death; and analysed data by framework analysis.SettingSixty-two maternal deaths in six districts in three provinces of Nepal.ResultsNearly half of the deceased women (45.2%) were primiparous and one-third had no formal education. About 40% were from Terai/Madhesi and 30.6% from lower caste. The most common place of death was private hospitals (41.9%), followed by public hospitals (29.1%). Nearly three-fourth cases were referred to higher health facilities and median time (IQR) of stay at the lower health facility was 120 (60–180) hours. Nearly half of deaths (43.5%) were attributable to more than one delay while first and third delay each contributed equally (25.8%). Lack of perceived need; perceived cost and low status; traditional beliefs and practices; physically inaccessible facilities and lack of service readiness and quality care were important factors in maternal deaths.ConclusionsThe first and third delays were the equal contributors of maternal deaths. Interventions related to birth preparedness, economic support and family planning need to be focused on poor and marginalised communities. Community management of quick transportation, early diagnosis of pregnancy risks, accommodation facilities near the referral hospitals and dedicated skilled manpower with adequate medicines, equipment and blood supplies in referral hospitals are needed for further reduction of maternal deaths in Nepal.

Objectives: Evolutionary perspectives on human childbirth have primarily focused on characteristics of our species in general, rather than variability within and between contemporary populations. We use an evolutionary framework to explore how physical and demographic characteristics of mothers shape the risks of childbirth complications in rural lowland Nepal, where childbearing typically commences in adolescence and chronic undernutrition is widespread, though maternal overweight is increasing in association with nutrition transition. Methods: We conducted secondary analyses of data from a cluster���randomized trial. Women aged 14���35 years were categorized by age, number of previous pregnancies, height, body mass index (BMI), husband's education, and household wealth. Multivariable logistic regression models tested whether these characteristics independently predicted risks of episiotomy and cesarean section (CS, n = 14 261), and obstructed labor (OL, n = 5185). Results: Risks were greatest among first���time adolescent mothers, though associations with age varied by outcome. Independent of age and parity, short stature and high BMI increased risks of CS and OL, whereas associations were weaker for episiotomy. Male offspring had increased risk of CS and OL but not episiotomy. Wealth was not associated with OL, but lower wealth and lower husband's education were associated with lower likelihood of episiotomy and CS. Conclusions: At the individual level, the risk childbirth complications is shaped by trade���offs between fertility, growth, and survival. Some biological markers of disadvantage (early childbearing, short stature) increased the risk, whereas low socio���economic status was associated with lower risk, indicating reduced access to relevant facilities. Independent of these associations, maternal age showed complex effects.

OBJECTIVES: In many South Asian communities, the majority of women are married during adolescence and reproduce before 20 years. Early reproduction may adversely affect maternal nutrition and linear growth, however whether early marriage has similar effects is unknown. Shorter women might also be preferentially chosen for earlier marriage. We hypothesized that early marriage and early pregnancy may each be associated with women's shorter height, independent of any selection effects. MATERIALS AND METHODS: We analyzed cross-sectional data on 7,146 women aged 20-30 years from rural lowland Nepal. Linear regression models tested associations of early marriage and early reproduction with height, adjusting for women's education and husbands' characteristics (education and wealth) that might index preferential selection of short young women for marriage. RESULTS: Median ages at marriage and first pregnancy were 15 and 18 years, respectively, with 20% pregnant

Few data exist on the prevalence of autism in low-income countries. We translated, adapted and tested the acceptability of a Nepali-language version of a screening tool for autism (Autism Quotient-10). Using this tool, we estimated autism prevalence in 4098 rural Nepali children aged 9–13 years. Fourteen children scored > 6 out of 10, indicative of elevated autistic symptomatology, of which 13 also screened positive for disability. If the AQ-10 screening tool is as sensitive and specific in the Nepali population as it is in the UK, this would yield an estimated true prevalence of 3 in 1000 (95% confidence interval 2–5 in 1000). Future research is required to validate this tool through in-depth assessments of high-scoring children. Electronic supplementary material The online version of this article (10.1007/s10803-018-3610-1) contains supplementary material, which is available to authorized users.

Diet quality is an important determinant of nutrition and food security and access can be constrained by changes in food prices and affordability. Poverty, malnutrition, and food insecurity are high in Nepal and may have been aggravated by the 2008 food price crisis. To assess the potential impact of the food price crisis on the affordability of a nutritionally adequate diet in the rural plains of Nepal, data on consumption patterns and local food prices were used to construct typical food baskets, consumed by four different wealth groups in Dhanusha district in 2005 and 2008. A modelled diet designed to meet household requirements for energy and essential nutrients at minimum cost, was also constructed using the ‘Cost of Diet’ linear programming tool, developed by Save the Children. Between 2005 and 2008, the cost of the four typical food baskets increased by 19% – 26% and the cost of the nutritionally adequate modelled diet increased by 28%. Typical food baskets of all wealth groups were low in macro and micronutrients. Income data for the four wealth groups in 2005 and 2008 were used to assess diet affordability. The nutritionally adequate diet was not affordable for poorer households in both 2005 and 2008. Due to an increase in household income levels, the affordability scenario did not deteriorate further in 2008. Poverty constrained access to nutritionally adequate diets for rural households in Dhanusha, even before the 2008 food price crisis. Despite increased income in 2008, households remain financially unable to meet their nutritional requirements. Electronic supplementary material The online version of this article (10.1007/s12571-018-0799-y) contains supplementary material, which is available to authorized users.

Highlights • Over-age attendance is increasing but remains under-studied in South Asia. • Children fall behind by entering pre-primary or primary late, and by repeating a grade during/after primary school. • Rural location, thin and uneducated mothers predicted late pre-primary entry. • Educational research and interventions need to focus on the earlier time-point of pre-primary. • Improving maternal nutrition and education may ensure timely progression of children in school.

Background: Early childbirth is associated with adverse maternal and child health outcomes. In South Asia, where women generally marry before having children, public health efforts need to focus on delaying marriage. Female education is widely considered the primary means to achieve this. However, it remains unclear how much education is required to delay marriage to the universal minimum age of 18 years, or what predicts marriage age in women lacking any education. This is crucial to address in the Terai region of Nepal which has the highest proportion of children out of school and where girls marry and have their first pregnancy early. Methods: We analyzed data from 6,406 women aged 23-30 years from a cluster-randomized trial in lowland Terai Nepal. Using Kaplan-Meier survival analysis, multivariable logistic and Cox proportional hazards regression models, we investigated associations between women's education level and age at marriage and first pregnancy, and the interval between these events. Among the uneducated women, we investigated associations of husband's education level with the same outcomes. Results: Compared to uneducated women, educated women had a greater probability of delaying marriage until the age of 18 years and of pregnancy until 20 years. Women needed to complete grade 9, and ideally 11, to substantially increase their odds of marrying after 18 years. Delaying first pregnancy to 20 years was largely due to marrying later; education had little extra effect. The association of marriage with first pregnancy age worked independently of education. However, later-marrying women, who generally had completed more education, had their first pregnancy sooner after marriage than earlier marrying women. Most uneducated women, regardless of their husbands' level of education, still married under the legal age of marriage. Conclusion: Delaying marriage to majority age requires greater efforts to ensure girls get to school in the first place, and complete secondary education. Since currently only 36% of girls in the Terai attend secondary school, parallel efforts to delay marriage are crucial to prevent early childbearing. Sexual and reproductive health programmes in school and in women's groups for married and uneducated adolescents may help prepare for marriage and pregnancy.

Background In Bangladesh, India and Nepal, neonatal outcomes of poor infants are considerably worse than those of better-off infants. Understanding how these inequalities vary by country and place of delivery (home or facility) will allow targeting of interventions to those who need them most. We describe socio-economic inequalities in newborn care in rural areas of Bangladesh, Nepal and India for all deliveries and by place of delivery. Methods We used data from surveillance sites in Bangladesh, India and from Makwanpur and Dhanusha districts in Nepal, covering periods from 2001 to 2011. We used literacy (ability to read a short text) as indicator of socioeconomic status. We developed a composite score of nine newborn care practices (score range 0–9 indicating infants received no newborn care to all nine newborn care practices). We modeled the effect of literacy and place of delivery on the newborn care score and on individual practices. Results In all study sites (60,078 deliveries in total), use of facility delivery was higher among literate mothers. In all sites, inequalities in newborn care were observed: the difference in new born care between literate and illiterate ranged 0.35–0.80. The effect of literacy on the newborn care score reduced after adjusting for place of delivery (range score difference literate-illiterate: 0.21–0.43). Conclusion Socioeconomic inequalities in facility care greatly contribute to inequalities in newborn care. Improving newborn care during home deliveries and improving access to facility care are a priority for addressing inequalities in newborn care and newborn mortality. Electronic supplementary material The online version of this article (10.1186/s12939-018-0834-9) contains supplementary material, which is available to authorized users.

Maternal and neonatal mortality rates are highest in the poorest countries, and financial barriers impede access to health care. Community loan funds can increase access to cash in rural areas, thereby reducing delays in care seeking. As part of a participatory intervention in rural Nepal, community women's groups initiated and managed local funds. We explore the factors affecting utilization and management of these funds and the role of the funds in the success of the women's group intervention. We conducted a qualitative study using focus group discussions, group interviews and unstructured observations. Funds may increase access to care for members of trusted 'insider' families adjudged as able to repay loans. Sustainability and sufficiency of funds was a concern but funds increased women's independence and enabled timely care seeking. Conversely, the perceived necessity to contribute may have deterred poorer women. While funds were integral to group success and increased women's autonomy, they may not be the most effective way of supporting the poorest, as the risk pool is too small to allow for repayment default.

Background The World Health Organization recommends participatory learning and action (PLA) in women’s groups to improve maternal and newborn health, particularly in rural settings with low access to health services. There have been calls to understand the pathways through which this community intervention may affect neonatal mortality. We examined the effect of women’s groups on key antenatal, delivery, and postnatal behaviours in order to understand pathways to mortality reduction. Methods and findings We conducted a meta-analysis using data from 7 cluster-randomised controlled trials that took place between 2001 and 2012 in rural India (2 trials), urban India (1 trial), rural Bangladesh (2 trials), rural Nepal (1 trial), and rural Malawi (1 trial), with the number of participants ranging between 6,125 and 29,901 live births. Behavioural outcomes included appropriate antenatal care, facility delivery, use of a safe delivery kit, hand washing by the birth attendant prior to delivery, use of a sterilised instrument to cut the umbilical cord, immediate wrapping of the newborn after delivery, delayed bathing of the newborn, early initiation of breastfeeding, and exclusive breastfeeding. We used 2-stage meta-analysis techniques to estimate the effect of the women’s group intervention on behavioural outcomes. In the first stage, we used random effects models with individual patient data to assess the effect of groups on outcomes separately for the different trials. In the second stage of the meta-analysis, random effects models were applied using summary-level estimates calculated in the first stage of the analysis. To determine whether behaviour change was related to group attendance, we used random effects models to assess associations between outcomes and the following categories of group attendance and allocation: women attending a group and allocated to the intervention arm; women not attending a group but allocated to the intervention arm; and women allocated to the control arm. Overall, women’s groups practising PLA improved behaviours during and after home deliveries, including the use of safe delivery kits (odds ratio [OR] 2.92, 95% CI 2.02–4.22; I2 = 63.7%, 95% CI 4.4%–86.2%), use of a sterile blade to cut the umbilical cord (1.88, 1.25–2.82; 67.6%, 16.1%–87.5%), birth attendant washing hands prior to delivery (1.87, 1.19–2.95; 79%, 53.8%–90.4%), delayed bathing of the newborn for at least 24 hours (1.47, 1.09–1.99; 68.0%, 29.2%–85.6%), and wrapping the newborn within 10 minutes of delivery (1.27, 1.02–1.60; 0.0%, 0%–79.2%). Effects were partly dependent on the proportion of pregnant women attending groups. We did not find evidence of effects on uptake of antenatal care (OR 1.03, 95% CI 0.77–1.38; I2 = 86.3%, 95% CI 73.8%–92.8%), facility delivery (1.02, 0.93–1.12; 21.4%, 0%–65.8%), initiating breastfeeding within 1 hour (1.08, 0.85–1.39; 76.6%, 50.9%–88.8%), or exclusive breastfeeding for 6 weeks after delivery (1.18, 0.93–1.48; 72.9%, 37.8%–88.2%). The main limitation of our analysis is the high degree of heterogeneity for effects on most behaviours, possibly due to the limited number of trials involving women’s groups and context-specific effects. Conclusions This meta-analysis suggests that women’s groups practising PLA improve key behaviours on the pathway to neonatal mortality, with the strongest evidence for home care behaviours and practices during home deliveries. A lack of consistency in improved behaviours across all trials may reflect differences in local priorities, capabilities, and the responsiveness of health services. Future research could address the mechanisms behind how PLA improves survival, in order to adapt this method to improve maternal and newborn health in different contexts, as well as improve other outcomes across the continuum of care for women, children, and adolescents., In a meta-analysis of randomized controlled trials, Nadine Seward and colleagues find that in Asian and African settings with limited access to medical services, participatory learning women’s groups are associated with improved perinatal health behaviors., Author summary Why was this study done? A systematic review and meta-analysis of trials of participatory learning and action in women’s groups found a 25% reduction in neonatal mortality associated with these groups, but the pathways to improved survival have not been explored using available evidence from all trials. We used data from cluster-randomised trials of women’s groups to explore behaviours in the antenatal, delivery, and postnatal periods in order to better explain the reduction in neonatal mortality associated with these groups. We also examined whether women who were assigned to the intervention arm and attended group meetings were more likely to have improved care practices than women who were also in the intervention arm but did not attend group meetings. What did the researchers do and find? We conducted a meta-analysis using individual-level data to explore the relationship between women’s groups and key behaviours in the antenatal, delivery, and postnatal periods. Our findings suggest that women’s groups are able to improve key behaviours for home deliveries including clean delivery practices and thermal care practices. To determine whether women who attended group meetings were more likely to have improved behaviours compared with women who did not attend, we compared behaviours between these women separately for the different trials. Overall, we found that women who attended group meetings were more likely to have improved behaviours than women who did not attend. What do these findings mean? Our meta-analysis showed that women’s groups were associated with improvements in critical practices including clean deliveries and appropriate thermal care for home deliveries. Evidence suggests that these care practices are essential for reducing neonatal mortality because of the importance of sepsis and hypothermia in areas with high neonatal mortality and low rates of facility births. Although this finding explains how women’s groups improved survival in these contexts, we also found that women’s groups improved survival in areas with lower neonatal mortality, such as rural Bangladesh and rural Malawi. It is possible that women’s groups were able to help families make more timely, better informed decisions about care seeking. Women’s groups have demonstrated flexibility in adapting to a shifting environment to improve birth outcomes through important pathways. Key to the continued reduction in adverse birth outcomes will be sustained improvement in community-level practices, as well as ensuring that health facilities are equipped to support quality care.

Aims: This study was done to identify and analyze obstetric near miss cases at health facilities of electoral constituency number 2 (EC 2) of Arghakhanchi district, Nepal. Methods: After receiving one day training on identifying obstetric near miss cases, health facility staff of EC 2 of Arghakhanchi district filled up WHO derived obstetric near miss forms for eight months duration. Causes of obstetric near miss cases were identified and analyzed in SPSS 16. Results : There were 31 obstetric near miss cases reported from different health facilities of EC 2 of Arghakhanchi. The commonest cause of obstetric near miss was Post-partum Hemorrhage (85%, n=26) followed by obstructed labor and ante partum hemorrhage (6%, n= 2) each. The leading cause of PPH was retained placenta/placental tissue in 55% cases (14) followed by atonic uterus (27%, n= 7). Two fifth of the mothers (39%, n=12) developed complication during labor. The most common complication developed after labor was hemorrhage. Conclusions : This study highlighted PPH as the most common serious obstetric problem in the health facilities and indicates the need for provision of blood transfusion at the health facility at least at Arghakhanchi. DOI: http://dx.doi.org/10.3126/njog.v9i2.11760

Introduction: The near miss concept and the criterion-based clinical audit are proposed as useful approaches for obtaining such information in newborn health care. There is currently no Standard definition and criteria for neonatal near miss especially for the community level intervention. Thus, lifesaving interventions could be an entry point to initiate the development of the neonatal near-miss definition. Mother and Infants Research Activities and Health Right International (HRI) developed a new tool for assessing neonatal near miss cases based on the Community based newborn care package programme. This is a part of operational research programme on strengthening the health facilities of Electoral constituency No; 2 of Arghakhanchi district of Nepal. The objective of this study was to identify and analyze neonatal near miss cases at different health facilities of Electoral constituency No; 2 of Arghakhanchi district, Nepal. Materials and Methods: One day of training on identifying neonatal near miss cases was given by an expert at Arghakhanchi district hospital to the health facilities staff in two groups. Health facility staffs were trained on identifying neonatal near miss cases and completing the modified neonatal near miss case forms. Neonatal near miss cases were documented for nine months period. Results: There were a total of 28 cases of neonatal near miss reported from different health facilities. Among them, 90% babies were delivered at health facility and 72% babies were of normal birth weight. Low birth weight incidence is 21% among near miss cases. Neonatal near miss contributed possible severe bacterial infection/ severe infection 47%, birth asphyxia in 43% cases and very low birth weight 7%. Conclusions: Birth asphyxia and PSBI were the two most common causes of neonatal near miss in the health facilities of Arghakhanchi district. There is a need to improve the quality of neonatal care in health facilities to properly manage these neonatal near miss cases which were referred to higher centre. DOI: http://dx.doi.org/10.3126/jnps.v34i2.9880 J Nepal Paediatr Soc 2014;34(2):115-118

Background Perinatal common mental disorders are a major cause of disability among women and have consequences for children's growth and development. We aimed to identify factors associated with psychological distress, a proxy for common mental disorders, among mothers in rural Dhanusha, Nepal. Methods We used data from 9078 mothers who were screened for distress using the 12-item General Health Questionnaire (GHQ-12) around six weeks after delivery. We assessed the association between GHQ-12 score and socioeconomic, gender-based, cultural and reproductive health factors using a hierarchical analytical framework and multilevel linear regression models. Results Using a threshold GHQ-12 score of ≥6 to indicate caseness, the prevalence of distress was 9.8% (886/9078). Factors that predicted distress were severe food insecurity (β 2.21 (95% confidence interval 1.43, 3.40)), having a multiple birth (2.28 (1.27, 4.10)), caesarean section (1.70 (0.29, 2.24)), perinatal health problems (1.58 (1.23, 2.02)), no schooling (1.37 (1.08, 1.73)), fewer assets (1.33 (1.10, 1.60)), five or more children (1.33 (1.09, 1.61)), poor or no antenatal care (1.31 (1.15, 1.48) p

Objectives To estimate small for gestational age birth prevalence and attributable neonatal mortality in low and middle income countries with the INTERGROWTH-21st birth weight standard.Design Secondary analysis of data from the Child Health Epidemiology Reference Group (CHERG), including 14 birth cohorts with gestational age, birth weight, and neonatal follow-up. Small for gestational age was defined as infants weighing less than the 10th centile birth weight for gestational age and sex with the multiethnic, INTERGROWTH-21st birth weight standard. Prevalence of small for gestational age and neonatal mortality risk ratios were calculated and pooled among these datasets at the regional level. With available national level data, prevalence of small for gestational age and population attributable fractions of neonatal mortality attributable to small for gestational age were estimated.Setting CHERG birth cohorts from 14 population based sites in low and middle income countries.Main outcome measures In low and middle income countries in the year 2012, the number and proportion of infants born small for gestational age; number and proportion of neonatal deaths attributable to small for gestational age; the number and proportion of neonatal deaths that could be prevented by reducing the prevalence of small for gestational age to 10%.Results In 2012, an estimated 23.3 million infants (uncertainty range 17.6 to 31.9; 19.3% of live births) were born small for gestational age in low and middle income countries. Among these, 11.2 million (0.8 to 15.8) were term and not low birth weight (≥2500 g), 10.7 million (7.6 to 15.0) were term and low birth weight (Conclusions In low and middle income countries, about one in five infants are born small for gestational age, and one in four neonatal deaths are among such infants. Increased efforts are required to improve the quality of care for and survival of these high risk infants in low and middle income countries.

Autism is a global phenomenon. Yet, there is a dearth of knowledge of how it is understood and its impact in low-income countries. We examined parents’ and professionals’ understanding of autism in one low-income country, Nepal. We conducted focus groups and semi-structured interviews with parents of autistic and non-autistic children and education and health professionals from urban and rural settings ( n = 106), asking questions about typical and atypical development and presenting vignettes of children to prompt discussion. Overall, parents of typically developing children and professionals had little explicit awareness of autism. They did, however, use some distinctive terms to describe children with autism from children with other developmental conditions. Furthermore, most participants felt that environmental factors, including in-utero stressors and birth complications, parenting style and home or school environment were key causes of atypical child development and further called for greater efforts to raise awareness and build community capacity to address autism. This is the first study to show the striking lack of awareness of autism by parents and professionals alike. These results have important implications for future work in Nepal aiming both to estimate the prevalence of autism and to enhance support available for autistic children and their families.

BACKGROUND: About half of the world's population is exposed to smoke from burning biomass fuels at home. The high airborne particulate levels in these homes and the health burden of exposure to this smoke are well described. Burning unprocessed biological material such as wood and dried animal dung may also produce high indoor endotoxin concentrations. OBJECTIVE: In this study we measured airborne endotoxin levels in homes burning different biomass fuels. METHODS: Air sampling was carried out in homes burning wood or dried animal dung in Nepal (n = 31) and wood, charcoal, or crop residues in Malawi (n = 38). Filters were analyzed for endotoxin content expressed as airborne endotoxin concentration and endotoxin per mass of airborne particulate. RESULTS: Airborne endotoxin concentrations were high. Averaged over 24 hr in Malawian homes, median concentrations of total inhalable endotoxin were 24 endotoxin units (EU)/m3 in charcoal-burning homes and 40 EU/m3 in wood-burning homes. Short cooking-time samples collected in Nepal produced median values of 43 EU/m3 in wood-burning homes and 365 EU/m3 in dung-burning homes, suggesting increasing endotoxin levels with decreasing energy levels in unprocessed solid fuels. CONCLUSIONS: Airborne endotoxin concentrations in homes burning biomass fuels are orders of magnitude higher than those found in homes in developed countries where endotoxin exposure has been linked to respiratory illness in children. There is a need for work to identify the determinants of these high concentrations, interventions to reduce exposure, and health studies to examine the effects of these sustained, near-occupational levels of exposure experienced from early life.

The Publisher regrets that an error occurred in the name of the 6th listed co-author for this paper. B. Matthias was listed in the original paper instead of M. Borchert; the correct listing can be seen above.

Women's groups, working through participatory learning and action, can improve maternal and newborn survival. We describe how they stimulated change in rural Nepal and the factors influencing their effectiveness. We collected data from 19 women's group members, 2 group facilitators, 16 health volunteers, 2 community leaders, 21 local men, and 23 women not attending the women's groups, through semi-structured interviews, group interviews, focus group discussions and unstructured observation of groups. Participants took photographs of their locality for discussion in focus groups using photoelicitation methods. Framework analysis procedures were used, and data fed back to respondents. When group members were compared with 11 184 women who had recently delivered, we found that they were of similar socioeconomic status, despite the context of poverty, and caste inequalities. Four mechanisms explain the women's group impact on health outcomes: the groups learned about health, developed confidence, disseminated information in their communities, and built community capacity to take action. Women's groups enable the development of a broader understanding of health problems, and build community capacity to bring health and development benefit.

Summary Background The negative effects of low birthweight on the later health of children in developing countries have been well studied. However, undertaking programmes to address this issue can be difficult since there is no simple correlation between increasing birthweight and improving child health. In 2005, we published results of a randomised controlled trial in Nepal, in which 1200 women received either iron and folic acid or a supplement that provided the recommended daily allowance of 15 vitamins and minerals, over the second and third trimesters of pregnancy. Here, we report on 2–3 years' follow-up of children born during the trial. Methods We visited children at home and obtained data for the primary outcomes of weight and height, for childhood illnesses, and maternal blood haemoglobin. The study is registered as an International Standard Randomised Controlled Trial, number ISRCTN88625934. Findings Between December, 2005, and December, 2006, we assessed 917 children (455 controls, 462 intervention) at a mean age of 2·5 years. Mean birthweight had been 77 g (95% CI 24–130) greater in the micronutrient group than in controls. At 2·5 years old, controls weighed a mean of 10·7 kg (SD 1·38), and those in the intervention group 10·9 kg (SD 1·54). Children of women who had taken multiple micronutrient supplements during pregnancy were a mean 204 g (95% CI 27–381) heavier than controls. They also had greater measurements than controls in the circumference of the head (2·4 mm [95% CI 0·6–4·3]), chest (3·2 mm [0·4–6·0]), and mid-upper arm (2·4 mm [1·1–3·7]), and in triceps skinfold thickness (2·0 mm [0·0–0·4]). Systolic blood pressure was slightly lower in the intervention group (2·5 mm Hg [0·5–4·6]). Interpretation In a poor population, the effects of maternal multiple micronutrient supplementation on the fetus persisted into childhood, with increases in both weight and body size. These increases were small, however, since those exposed to micronutrients had an average of 2% higher weight than controls. The public-health implications of changes in weight and blood pressure need to be clarified through further follow-up.

Secondary sources of information indicate that the proportion of child deaths due to injuries is increasing in Nepal. This study aimed to describe the epidemiology of unintentional injuries in children, explore risk factors and estimate the burden faced by families and the community in the Makwanpur district. We conducted a household survey in Makwanpur, covering 3441 households. Injuries that occurred during the 12 months before the survey and required treatment or caused the child to be unable to take part in usual activities for three or more days were included. We identified 193 cases of non-fatal unintentional child injuries from 181 households and estimated an annual rate of non-fatal injuries of 24.6/1000 children, rates for boys were double (32.7/1000) that for girls (16.8/1000). The rates were higher among the children of age groups 1–4 years and 5–9 years. Falls were the most common cause of non-fatal child injuries followed by burns in preschool children and road traffic injuries were the most likely cause in adolescence. Mean period of disability following injury was 25 days. The rates and the mechanisms of injury vary by age and gender. Falls and burns are currently the most common mechanisms of injury amongst young children around rural homes.

BACKGROUND: Globally, puerperal sepsis accounts for an estimated 8-12% of maternal deaths, but evidence is lacking on the extent to which clean delivery practices could improve maternal survival. We used data from the control arms of four cluster-randomised controlled trials conducted in rural India, Bangladesh and Nepal, to examine associations between clean delivery kit use and hand washing by the birth attendant with maternal mortality among home deliveries. METHODS: We tested associations between clean delivery practices and maternal deaths, using a pooled dataset for 40,602 home births across sites in the three countries. Cross-sectional data were analysed by fitting logistic regression models with and without multiple imputation, and confounders were selected a priori using causal directed acyclic graphs. The robustness of estimates was investigated through sensitivity analyses. RESULTS: Hand washing was associated with a 49% reduction in the odds of maternal mortality after adjusting for confounding factors (adjusted odds ratio (AOR) 0.51, 95% CI 0.28-0.93). The sensitivity analysis testing the missing at random assumption for the multiple imputation, as well as the sensitivity analysis accounting for possible misclassification bias in the use of clean delivery practices, indicated that the association between hand washing and maternal death had been over estimated. Clean delivery kit use was not associated with a maternal death (AOR 1.26, 95% CI 0.62-2.56). CONCLUSIONS: Our evidence suggests that hand washing in delivery is critical for maternal survival among home deliveries in rural South Asia, although the exact magnitude of this effect is uncertain due to inherent biases associated with observational data from low resource settings. Our findings indicating kit use does not improve maternal survival, suggests that the soap is not being used in all instances that kit use is being reported.

The South Asian Association for Regional Cooperation (SAARC) is an organization of eight countries--Bangladesh, Bhutan, India, the Maldives, Nepal, Pakistan, Sri Lanka and Afghanistan. The major objectives of this review are to examine trends and progress in newborn and neonatal health care in the region. A landscape analysis of the current state of neonatal mortality, stillbirths and trends over the years for each country and the effective interventions to reduce neonatal mortality and stillbirths was undertaken. A modelling exercise using the Lives Saved Tool (LiST) was also undertaken to determine the impact of scaling up a set of essential interventions on neonatal mortality and stillbirths. The findings demonstrate that there is an unacceptably high and uneven burden of neonatal mortality and stillbirths in the region which together account for 39% of global neonatal deaths and 41% of global stillbirths. Progress is uneven across countries in the region, with five of the eight SAARC countries having reduced their neonatal mortality rate by more than 50% since 1990, while India (43%), Afghanistan (29%) and Pakistan (25%) have made slower progress and will not reach their MDG4 targets. The major causes of neonatal mortality are intrapartum-related deaths, preterm birth complications and sepsis which account for nearly 80% of all deaths. The LiST analysis shows that a gradual increase in coverage of proven available interventions until 2020 followed by a uniform scale-up to 90% of all interventions until 2030 could avert 52% of neonatal deaths (0.71 million), 29% of stillbirths (0.31 million) and achieve a 31% reduction in maternal deaths (0.25 million). The analysis demonstrates that the Maldives and Sri Lanka have done remarkably well while other countries need greater attention and specific focus on strategies to improve neonatal health.

OBJECTIVES: Growth patterns in early life are increasingly linked with subsequent cardio-metabolic risk, but the underlying mechanisms require elucidation. We have developed a theoretical model of blood pressure, treating it as a function of homeostatic metabolic capacity, and antagonistic metabolic load. We sought to differentiate prenatal and postnatal components of metabolic capacity, and to identify intergenerational contributions to offspring capacity and load. METHODS: We followed up at 8 years a cohort of children originally recruited into a randomized trial of maternal micronutrient supplementation in pregnancy. Maternal anthropometry was measured at recruitment. Offspring anthropometry was measured at birth, 2 years and 8 years. Offspring blood pressure, kidney size, and body composition were measured at 8 years. Regression analysis was used to investigate potential associations of maternal phenotype, birth phenotype, and current body composition with kidney size and blood pressure. RESULTS: Blood pressure was positively associated with body fat, but negatively associated with birth weight and relative leg length. Kidney size was positively associated with birth weight but not with relative leg length. Adjusting for adiposity, blood pressure was independently negatively associated with birth weight, relative leg length, and kidney length. Maternal height and BMI predicted offspring size at birth and at 8 years, but not blood pressure. CONCLUSIONS: Our data provide support for the capacity-load model of blood pressure in Nepalese children. Fetal and postnatal growth and kidney dimensions all contribute to metabolic capacity. Maternal phenotype contributed to offspring capacity and load, but these associations did not propagate to blood pressure. Am. J. Hum. Biol., 2016. © 2016 The Authors American Journal of Human Biology Published by Wiley Periodicals, Inc.

Asthma is common in children worldwide, although its prevalence varies substantially by location. The prevalence of wheeze over a 12-month period ranged from 2.1% to 32.2% in the older age group (13–14 years) and 4.1% to 32.1% in the younger age group (6–7 years) [1]. There is a positive association between current symptoms of asthma in younger and older children with gross national income [2], and it is generally slightly less common in girls than boys in the younger group [1–3]. Exposure to air pollution is associated with asthma exacerbations. Odds ratios for wheeze in the past year and the use of solely an open fire for cooking were 2.17 (95% CI 1.64–2.87) for children aged 6–7 years and 1.35 (95% CI 1.11–1.64) for children aged 13–14 years [4]. Nepalese children are exposed to high levels of indoor air pollution from the burning of biomass fuels [5]. This study aimed to estimate their prevalence of asthma, and to investigate the association of air pollution and risk of wheeze and rhinitis symptoms using personal exposure estimates of air pollution., Amongst children in rural Nepal, an association of dry cough with air pollution was seen only in boys http://ow.ly/MOa5u

Background Injuries accounted for 23% of all deaths in children and adolescents in Nepal during 2010 (n = 3,700). Despite this, there is no national death registration or injury surveillance system. Non-fatal injuries are many times more common than fatal injuries and may leave the injured person with lifelong consequences. Children in low-income settings are exposed to widespread risks of injuries but there is little awareness of how they can be prevented. Community mobilisation has been shown to be effective to reduce maternal and neonatal morbidity. This study aimed to develop a child safety programme and assess the feasibility of delivering the programme through a community mobilisation approach. Methods We developed a culturally appropriate, educational programme for Female Community Health Volunteers that included both primary and secondary prevention materials for unintentional child injuries. We determined the feasibility of evaluating its effectiveness through the mobilisation of women’s groups in rural Nepal. Ten women’s groups across 9 wards in one village development committee area completed the programme during 6 monthly meetings. Parent-reported injuries were collected through a notification system established for this study. Experience of the programme by women’s group participants and leaders was assessed through a structured questionnaire and process measures assessed the delivery and reach of the programme. Results Programme resources were developed for this setting and adapted following feedback from users. Nine FCHVs received first-aid training and shown how to use the facilitation manual and injury prevention resources. The FCHVs convened 10 women’s groups to run over 6 months with 24–29 mothers attending each meeting (290 mothers participated in total). Each group presented their views on child injury risks and proposed prevention activities at local public meetings. Women reported 155 injuries to children under 18 years during 7 months of follow up using the notification system. Conclusions It is feasible to develop and implement a community mobilisation intervention where women’s groups work together with local FCHVs to prevent injuries in children. The intervention was well received by the women’s groups and by community members. The effectiveness and cost effectiveness of the intervention should now be evaluated through an experimental study. Electronic supplementary material The online version of this article (doi:10.1186/s12889-015-1783-5) contains supplementary material, which is available to authorized users.

BACKGROUND: Multiple micronutrient supplementation of Nepalese women during pregnancy is associated with a significant increase in birth weight. OBJECTIVE: We tested the hypothesis that improved birth weight in infants of mothers supplemented with micronutrients is associated with a decrease in inflammatory responses and an increase in the production of T helper 1 cells and T helper 2 cells. DESIGN: The study was embedded in a randomized controlled trial of 15 micronutrients, compared with iron-folate supplementation (control), given during pregnancy with the aim of increasing birth weight. Blood samples were collected at 32 wk of gestation, 12-20 wk after supplementation began, for the measurement of inflammatory markers. Breast-milk samples were collected 1 mo after delivery for the measurement of the ratio of milk sodium to potassium (milk Na:K). In an opportunistically selected subgroup of 70 women, mitogen-stimulated cytokine production was measured ex vivo in whole blood. RESULTS: Blood eosinophils; plasma concentrations of the acute phase reactants C-reactive protein, alpha(1)-acid glycoprotein (AGP), neopterin, and ferritin; milk Na:K; and the production of interleukin (IL) 10, IL-4, interferon gamma, and tumor necrosis factor alpha in whole blood did not differ significantly between the supplemented and control groups. Plasma C-reactive protein and AGP were higher in women who had a preterm delivery, and AGP was higher in women who delivered a low-birth-weight term infant than in women who delivered a normal-birth-weight term infant. CONCLUSIONS: The results indicate an association between systemic inflammation in late pregnancy and compromised delivery outcome in Nepalese women but do not support the hypothesis that multiple micronutrient supplementation changes cytokine production or inflammatory markers.

BACKGROUND: Neonatal mortality is the biggest contributor to global mortality of children younger than 5 years, and low birthweight is a crucial underlying factor. We tested the hypotheses that antenatal multiple micronutrient supplementation would increase infant birthweight and gestational duration. METHODS: We did a double-blind, randomised controlled trial in Dhanusha district, Nepal. Women attending for antenatal care with singleton pregnancies at up to 20 weeks' gestation were invited to participate. Participants were randomly allocated either routine iron and folic acid supplements (control; n=600) or a multiple micronutrient supplement providing a recommended daily allowance of 15 vitamins and minerals (intervention; n=600). Supplementation began at a minimum of 12 weeks' gestation and continued until delivery. Primary outcome measures were birthweight and gestational duration. Analysis was by intention to treat. The study is registered as an International Standard Randomised Controlled Trial, number ISRCTN88625934. FINDINGS: Birthweight was available for 523/600 infants in the control group and 529/600 in the intervention group. Mean birthweight was 2733 g (SD 422) in the control group and 2810 g (453) in the intervention group, representing a mean difference of 77 g (95% CI 24-130; p=0.004) and a relative fall in the proportion of low birthweight by 25%. No difference was recorded in the duration of gestation (0.2 weeks [-0.1 to 0.4]; p=0.12), infant length (0.3 cm [-0.1 to 0.6]; p=0.16), or head circumference (0.2 cm [-0.1 to 0.4]; p=0.18). INTERPRETATION: In a poor community in Nepal, consumption of a daily supplement containing a recommended daily allowance of 15 micronutrients in the second and third trimesters of pregnancy was associated with increased birthweight when compared with a standard iron and folic acid preparation. The effects on perinatal morbidity and mortality need further comparisons between studies. Published online March 3, 2005 http://image.thelancet.com/extras/04art11045web.pdf.

The persistence of high perinatal and neonatal mortality rates in many developing countries make efforts to improve perinatal care in the home and at local health facilities important public health concerns. We describe a study which aims to evaluate a community-level participatory intervention in rural Nepal. The effectiveness of community-based action research interventions with mothers and other key members of the community in improving perinatal health outcomes is being examined using a cluster randomized, controlled trial covering a population of 28 000 married women of reproductive age. The unit of randomization was the village development committee (VDC): 12 VDCs receive the intervention while 12 serve as controls. The key elements of the intervention are the activities of female facilitators, each of whom works in one VDC facilitating the activities of women's groups in addressing problems in pregnancy, childbirth and the newborn period. Each group moves through a participatory planning cycle of assessment, sharing experiences, planning, action and reassessment, with the aim of improving essential maternal and newborn care. Outcomes assessed are neonatal and perinatal mortality rates, changes in patterns of home care, health care seeking and referral. The study also aims to generate programmatic information on the process of implementation in communities.

Background Delivery of essential newborn care is key to reducing neonatal mortality rates, yet coverage of protective birth practices remains incomplete and variable, with or without skilled attendance. Evidence of changes over time in newborn care provision, disaggregated by care practice and delivery type, can be used by policymakers to review efforts to reduce mortality. We examine such trends in four areas using control arm trial data. Methods and Findings We analysed data from the control arms of cluster randomised controlled trials in Bangladesh (27 553 births), eastern India (8 939), Dhanusha, Nepal (15 344) and Makwanpur, Nepal (6 765) over the period 2001–2011. For each trial, we calculated the observed proportion of attended births and the coverage of WHO essential newborn care practices by year, adjusted for clustering and stratification. To explore factors contributing to the observed trends, we then analysed expected trends due only to observed shifts in birth attendance, accounted for stratification, delivery type and statistically significant interaction terms, and examined disaggregated trends in care practice coverage by delivery type. Attended births increased over the study periods in all areas from very low rates, reaching a maximum of only 30% of deliveries. Newborn care practice trends showed marked heterogeneity within and between areas. Adjustment for stratification, birth attendance and interaction revealed that care practices could change in opposite directions over time and/or between delivery types – e.g. in Bangladesh hygienic cord-cutting and skin-to-skin contact fell in attended deliveries but not home deliveries, whereas in India birth attendant hand-washing rose for institutional deliveries but fell for home deliveries. Conclusions Coverage of many essential newborn care practices is improving, albeit slowly and unevenly across sites and delivery type. Time trend analyses of birth patterns and essential newborn care practices can inform policy-makers about effective intervention strategies.

Socioeconomic status (SES) is associated with childhood anthropometry, but little is known about how it is associated with tissue growth and body composition. To investigate this, we looked at components of SES at birth with growth in early and mid‐childhood, and body composition in a longitudinal study in Nepal. The exposure variables (material assets, land ownership, and maternal education) were quantified from questionnaire data before birth. Anthropometry data at birth, 2.5 and 8.5 years, were normalized using WHO reference ranges and conditional growth calculated. Associations with child growth and body composition were explored using multiple regression analysis. Complete anthropometry data were available for 793 children. There was a positive association between SES and height‐for‐age and weight‐for‐age, and a reduction in odds of stunting and underweight for each increase in rank of SES variable. Associations tended to be significant when moving from the lower to the upper asset score, from none to secondary education, and no land to >30 dhur (~500 m2). The strongest associations were for maternal secondary education, showing an increase of 0.6–0.7 z scores in height‐for‐age and weight‐for‐age at 2.5 and 8.5 years and 0.3 kg/m2 in fat and lean mass compared to no education. There was a positive association with conditional growth in the highest asset score group and secondary maternal education, and generally no association with land ownership. Our results show that SES at birth is important for the growth of children, with a greater association with fat mass. The greatest influence was maternal secondary education.

INTRODCTION: Low birth weight (LBW) is a major risk factor for neonatal death. However most neonates in low-income countries are not weighed at birth. This results in many LBW infants being overlooked. Female community health volunteers (FCHVs) in Nepal are non-health professionals who are living in local communities and have already worked in a field of reproductive and child health under the government of Nepal for more than 20 years. The effectiveness of involving FCHVs to detect LBW infants and to initiate prompt action for their care was studied in rural areas of Nepal. METHODS: FCHVs were tasked with weighing all neonates born in selected areas using color-coded spring scales. Supervisors repeated each weighing using electronic scales as the gold standard comparator. Data on the relative birth sizes of the infants as assessed by their mothers were also collected and compared with the measured weights. Each of the 205 FCHVs involved in the study was asked about the steps that she would take when she came across a LBW infant and knowledge of zeroing a spring scale was also assessed through individual interviews. The effect of the background social characteristics of the FCHVs on their performance was examined by logistic regression. This study was nested within a community-based neonatal sepsis-management intervention surveillance system which facilitated an assessment of the performance of the FCHVs in weighing neonates coverage of FCHVs visits and weighing of babies through maternal interviews. RESULTS: A total of 462 babies were weighed using both spring scales and electronic scales within 72 hours of birth. The prevalence of LBW as assessed by the gold standard method was 28%. The sensitivity of detection of LBW by FCHVs was 89% whereas the sensitivity of the mothers perception of size at birth was only 40%. Of the 205 FCHVs participating in the study 70% of FCHVs understood what they should do when they identified LBW and very low birth weight (VLBW) infants. Ninety-six per cent could describe how to zero a scale and approximately 50% could do it correctly. Seventy-seven per cent of FCHVs weighed infants at least once during the study period and 19 of them (12%) miscategorized infant weights. Differences were not detected between the background social characteristics of FCHVs who miscategorized infants and those who did not. On the basis of maternal reporting 67% of FCHVs who visited infants had weighed them. CONCLUSIONS: FCHVs are able to correctly identify LBW and VLBW infants using spring scales and describe the correct steps to take after identification of these infants. Use of FCHVs as newborn care providers allows for utilization of their logistical geographical and cultural strengths particularly a high level of access to neonates that can complement the Nepalese healthcare system. Providing additional training to and increasing supervision of local FCHVs regarding birth weight measurement will increase the identification of high-risk neonates in resource-limited settings.

This nested case-control study compares the characteristics of mothers having home or institutional deliveries in Kathmandu, Nepal, and explores the reasons given by mothers for a home delivery. The delivery patterns of mothers were identified in a cross-sectional survey of two communities: an urban area of central Kathmandu (Kalimati) and a peri-urban area (Kirtipur and Panga) five kilometres from the city centre. 357 pregnant women were identified from a survey of 6130 households: 183 from 3663 households in Kirtipur and Panga, 174 from 2467 households in Kalimati. Methods involved a structured baseline household questionnaire and detailed follow-up of identified pregnant women with structured and semi-structured interviews in hospital and the community. The main outcome measures were social and economic household details of pregnant women; pregnancy and obstetric details; place of delivery; delivery attendant; and reasons given for home delivery. The delivery place of 334/357 (94%) of the pregnant women identified at the survey was determined. 272 (81%) had an institutional delivery and 62 (19%) delivered at home. In univariate analysis comparing home and institutional deliverers, maternal education, parity, and poverty indicators (income, size of house, ownership of house) were associated with place of delivery. After multivariate analysis, low maternal educational level (no education, OR 5.04 [95% CI 1.61-15.8], class 1-10, OR 3.36 [1.04-10.8] compared to those with higher education) and multiparity (OR 3.1 [1.63-5.74] compared to primiparity) were significant risk factors for a home delivery. Of home deliverers, only 24% used a traditional birth attendant, and over half were unplanned due to precipitate labour or lack of transport. We conclude that poor education and multiparity rather than poverty per se increase the risk of a home delivery in Kathmandu. Training TBAs in this setting would probably not be cost-effective. Community-based midwife-run delivery units could reduce the incidence of unplanned home deliveries.

Background: In Nepal, childhood unintentional injury is an emerging public health problem but it has not been prioritised on national health agenda. There is lack of literature on community perceptions about child injuries. This study has explored community perceptions about child injuries and how injuries can be prevented. Methods. Focus group discussions were conducted with mothers, school students and community health volunteers from urban and rural parts of Makwanpur district in Nepal. FGDs were conducted in Nepali languages. These were recorded, transcribed and translated into English. A theoretical framework was identified and thematic analysis conducted. Results: Three focus group discussions, with a total of 27 participants, took place. Participants were able to identify examples of child injuries which took place in their community but these generally related to fatal and severe injuries. Participants identified risk factors such as the child's age, gender, behaviours and whether they had been supervised. Consequences of injuries such as physical and psychological effects, impact on household budgets and disturbance in household plans were identified. Suggestions were made about culturally appropriate prevention measures, and included; suitable supervision arrangements, separation of hazards and teaching about safety to the parents and children. Conclusion: Community members in Nepal can provide useful information about childhood injuries and their prevention but this knowledge is not transferred into action. Understanding community perceptions about injuries and their prevention can contribute to the development of preventive interventions in low income settings. © 2014 Pant et al.; licensee BioMed Central Ltd.

AIMS: To compare two cotside methods of blood glucose measurement (HemoCue and Reflolux II) against a standard laboratory method for the detection of neonatal hypoglycaemia in a developing country maternity hospital where hypoglycaemia is common. METHODS: 94 newborn infants and 75 of their mothers had blood glucose assessed on the same venous sample using three different methods in the Special Care Baby Unit and postnatal wards, Prasuti Griha Maternity Hospital, Kathmandu, Nepal: HemoCue and Reflolux II at the cotside; Roche Ultimate glucose oxidase method (GOM) in the laboratory. RESULTS: The mean (SD) values for blood glucose in newborn infants were GOM 2.5 (1.1) mmol/l; Reflolux II 2.1 (0.9); and HemoCue 4.2 (1.2). For mothers the values were GOM 5.3 (1.2) mmol/l; Reflolux II 3.6 (1.2); and HemoCue 5.6 (1.0). Bland-Altman plots showed that Reflolux II consistently underreads GOM blood glucose in neonates by 0.5 mmol/l (SD 0.7) and that HemoCue overreads glucose by 1.7 mmol/l (SD 0.8). For the detection of hypoglycaemia (< 2.0 mmol/l), Reflolux II achieved a sensitivity of 83%, a specificity of 62%, and a likelihood ratio of 2.2. HemoCue produced a sensitivity of 0% and a specificity of 100% using measured values. If 2.0 mmol were subtracted from all Hemocue values this rose to 81% and 68% and a likelihood ratio of 2.5. CONCLUSION: Although more accurate than Reflolux II for the measurement of blood glucose in mothers, HemoCue overreads glucose concentrations in neonates and is therefore potentially dangerous as a screening method for neonatal hypoglycaemia. Reflolux II is useful as a screening method for high risk infants (low birthweight, post-term) and could achieve a post-test probability of detecting hypoglycaemia in a high risk setting like Nepal of 50-60%.

Background Autism is a global phenomenon. Epidemiological studies estimate that 1–2% of children worldwide lie on the autism spectrum,1 with approximately 52 million individuals with autism across the globe. These estimates are largely driven, however, by prevalence estimates from high-income countries (HIC). Virtually no data exist, however, on the prevalence of autism in low-income countries (LIC) and none in a LIC rural setting. Aims Methods The Autism Quotient-10 (AQ-10) is a well-validated brief questionnaire of the 10 statements most strongly predictive of a diagnosis of autism in a UK population of children (sensitivity: 95%; specificity: 97%).2 We translated the AQ-10 – adolescent version in discussion with UK and Nepali paediatricians and clinical psychologists. The translated version was further developed and tested for acceptability in 3 focus groups of parents (n = 25). It was then piloted as a questionnaire with 136 families, following which minor edits were made only and additional fieldworker training provided. We conducted face-to-face interviews with 3984 parents from a cohort of 10–13 year-old children recruited from a 10-year follow-up study of a trial of women’s participatory groups.3 These families live in Makwanpur, a rural district of Nepal. Results Eleven out of 3984 children scored greater than 6 out of 10, indicative of autistic symptomatology. If the AQ-10 screening tool is as sensitive and specific in the Nepali population as it is in the UK, this would give an estimated true prevalence of 3 in 1000 (95% confidence interval 2 to 5 in 1000).4 Conclusion This is the first study to estimate prevalence of autism in a rural LIC setting. Prevalence estimates were lower than those in HIC. Future research is required to validate this tool through in-depth comprehensive assessments of high-scoring children. This preliminary estimate, combined with complementary research showing the lack of awareness of autism by Nepali professionals and parents, stresses the need to develop services to support families and children with atypical development in rural LIC settings.

Aim There has been a renewed focus globally on neonatal mortality as the deadline for the Millennium Development Goals approaches.1 Little is known about the neurodevelopmental consequences for survivors of complications in pregnancy, labour and the neonatal period in in low income countries outside of small, selective and typically urban facility studies.2 We ask which antenatal, birth and neonatal factors are associated with disability at age eleven in a large community recruited birth cohort from rural Nepal. Methods This cohort of 6,285 live births was recruited during a cluster randomised control trial of participatory women’s group on neonatal mortality.3,4 At age eleven 4,219 children were available for detailed follow up assessment including disability screening, with a retention rate in survivors of 72% (Figure 1). Disability was assessed by face to face interview using the newly developed UN/UNICEF Module on Child Functioning and Disability.5 To minimise the risk of posthoc testing first a list of hypothesised risk factors for adverse outcome was drawn up which was then consummated with the available data (Table 1). Factors with a univariate significance of Results Overall prevalence of disability was 7.4%. Maternal underweight (Odds Ratio (OR) 1.44 (95% confidence interval 1.01–2.08)), maternal cohabitation under 16 years of age (OR 1.50 (1.13–2.00)), increased weight at 1 month (per standard deviation OR 0.82 (0.71–0.95)) and reported diarrhoea and vomiting within the first 4 weeks of life (OR 2.48 (1.58–3.89)) were significantly associated with disability. The majority of hypothesised risk factors, including prematurity, were not significant on multivariable analysis (Table 2). Conclusions The relationship between poverty, maternal malnutrition and poor neurodevelopmental outcome is well recognised6 and our findings here emphasise the importance of breaking this cycle. The lack of association of most recognised risk factors for adverse outcome in high income settings may be due to high mortality and survival bias. As the neonatal mortality rate falls in countries like Nepal future research will need to revisit the relationship between birth environment and disability.

Background Neonatal mortality remains high in rural Nepal. Previous work suggests that local women's groups can effect significant improvement through community mobilisation. The possibility of identification and management of newborn infections by community-based workers has also arisen. Methods/Design The objective of this trial is to evaluate the effects on newborn health of two community-based interventions involving Female Community Health Volunteers. MIRA Dhanusha community groups: a participatory intervention with women's groups. MIRA Dhanusha sepsis management: training of community volunteers in the recognition and management of neonatal sepsis. The study design is a cluster randomized controlled trial involving 60 village development committee clusters allocated 1:1 to two interventions in a factorial design. MIRA Dhanusha community groups: Female Community Health Volunteers (FCHVs) are supported in convening monthly women's groups. Nine groups per cluster (270 in total) work through two action research cycles in which they (i) identify local issues around maternity, newborn health and nutrition, (ii) prioritise key problems, (iii) develop strategies to address them, (iv) implement the strategies, and (v) evaluate their success. Cycle 1 focuses on maternal and newborn health and cycle 2 on nutrition in pregnancy and infancy and associated postpartum care practices. MIRA Dhanusha sepsis management: FCHVs are trained to care for vulnerable newborn infants. They (i) identify local births, (ii) identify low birth weight infants, (iii) identify possible newborn infection, (iv) manage the process of treatment with oral antibiotics and referral to a health facility to receive parenteral gentamicin, and (v) follow up infants and support families. Primary outcome: neonatal mortality rates. Secondary outcomes: MIRA Dhanusha community group: stillbirth, infant and under-two mortality rates, care practices and health care seeking behaviour, maternal diet, breastfeeding and complementary feeding practices, maternal and under-2 anthropometric status. MIRA Dhanusha sepsis management: identification and treatment of neonatal sepsis by community health volunteers, infection-specific neonatal mortality. Trial Registration no ISRCTN: ISRCTN87820538

Early childhood growth retardation persists in developing countries despite decades of nutritional interventions. Adequate food is necessary, but not sufficient, to ensure normal growth where there is ubiquitous exposure to infection. Pathways associated with infection, small intestinal mucosal damage and chronic immunostimulation remain largely undemonstrated in countries other than The Gambia. We conducted a longitudinal study of one squatter and one middle-class group (n 86, 3–18 month olds) to assess these relationships in Nepal. Growth, mucosal damage index (MDI; urinary lactose:creatinine ratio adjusted for body weight), morbidity reports, and blood concentrations of albumin, α-1-acid glycoprotein, IgG and Hb, were recorded monthly. Growth status worsened dramatically from 6 to 18 months, with squatters more stunted (height-for-age Z-score (HAZ), P Z-score (WAZ), P = 0·009) than middle class. IgG increased with age, was elevated in squatter children, and negatively related to WAZ (P = 0·034). MDI showed significant negative associations with growth performance, explaining 9 and 19 % of height and weight deficits (ΔHAZ, P = 0·004; ΔWAZ, P P

Public health interventions usually operate at the level of groups rather than individuals, and cluster randomized controlled trials (RCTs) are one means of evaluating their effectiveness. Using examples from six such trials in Bangladesh, India, Malawi and Nepal, we discuss our experience of the ethical issues that arise in their conduct. We set cluster RCTs in the broader context of public health research, highlighting debates about the need to reconcile individual autonomy with the common good and about the ethics of public health research in low-income settings in general. After a brief introduction to cluster RCTs, we discuss particular challenges we have faced. These include the nature of - and responsibility for - group consent, and the need for consent by individuals within groups to intervention and data collection. We discuss the timing of consent in relation to the implementation of public health strategies, and the problem of securing ethical review and approval in a complex domain. Finally, we consider the debate about benefits to control groups and the standard of care that they should receive, and the issue of post-trial adoption of the intervention under test.