Generational trends in the transition to womanhood in lowland rural Nepal: Changes in the meaning of early marriage

OBJECTIVE

In South Asia, studies show secular trends toward slightly later women's marriage and first reproduction. However, data on related biological and social events, such as menarche and age of coresidence with husband, are often missing from these analyses. We assessed generational trends in key life events marking the transition to womanhood in rural lowland Nepal.

METHODS

We used data on 110 co-resident mother-in-law (MIL) and daughter-in-law (DIL) dyads. We used paired t-tests and chi-squared tests to evaluate generational trends in women's education, and mean age at menarche, marriage, cohabitation with husband, and first reproduction of MIL and DIL dyads. We examined norms held by MILs and DILs on a daughter's life opportunities.

RESULTS

On average, MIL was 29 years older than DIL (60 years vs. 31 years). Both groups experienced menarche at average age 13.8 years. MIL was married at average 12.4 years, before menarche, and cohabitated with husbands at average 14.8 years. DIL was simultaneously married and cohabitated with husbands after menarche, at average 15 years. DIL was marginally more educated than MIL but had their first child on average 0.8 years earlier (95% CI -1.4, -0.1). MIL and DIL held similar norms on daughters' education and marriage.

CONCLUSION

While social norms remain similar, the meaning of "early marriage" and use of menarche in marriage decisions has changed in rural lowland Nepal. Compared to DIL, MIL who was married earlier transitioned to womanhood more gradually. However, DIL was still married young, and had an accelerated trajectory to childbearing.

Patterns of domestic exposure to carbon monoxide and particulate matter in households using biomass fuel in Janakpur, Nepal

Household Air Pollution (HAP) from biomass cooking fuels is a major cause of morbidity and mortality in low-income settings worldwide. In Nepal the use of open stoves with solid biomass fuels is the primary method of domestic cooking. To assess patterns of domestic air pollution we performed continuous measurement of carbon monoxide (CO) and particulate Matter (PM2.5) in 12 biomass fuel households in Janakpur, Nepal. We measured kitchen PM2.5 and CO concentrations at one-minute intervals for an approximately 48-h period using the TSI DustTrak II 8530/SidePak AM510 (TSI Inc, St. Paul MN, USA) or EL-USB-CO data logger (Lascar Electronics, Erie PA, USA) respectively. We also obtained information regarding fuel, stove and kitchen characteristics and cooking activity patterns. Household cooking was performed in two daily sessions (median total duration 4 h) with diurnal variability in pollutant concentrations reflecting morning and evening cooking sessions and peak concentrations associated with fire-lighting. We observed a strong linear relationship between PM2.5 measurements obtained by co-located photometric and gravimetric monitoring devices, providing local calibration factors of 4.9 (DustTrak) and 2.7 (SidePak). Overall 48-h average CO and PM2.5 concentrations were 5.4 (SD 4.3) ppm (12 households) and 417.6 (SD 686.4) μg/m3 (8 households), respectively, with higher average concentrations associated with cooking and heating activities. Overall average PM2.5 concentrations and peak 1-h CO concentrations exceeded WHO Indoor Air Quality Guidelines. Average hourly PM2.5 and CO concentrations were moderately correlated (r = 0.52), suggesting that CO has limited utility as a proxy measure for PM2.5 exposure assessment in this setting. Domestic indoor air quality levels associated with biomass fuel combustion in this region exceed WHO Indoor Air Quality standards and are in the hazardous range for human health.

Validity of self-reported versus actual age in Nepali children and young people

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Self-reported age is a potential source of misclassification bias in International Surveys.

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We compare objectively recorded age with self-reported age at mean age 11.5 years in 3943 children in rural Nepal.

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There was high agreement between actual and self-reported age with an error rate of 7%.

Acceptability and Reliability of the Bayley Scales of Infant Development III Cognitive and Motor Scales among Children in Makwanpur

BACKGROUND

The Bayley Scales of Infant Development III (BSID III) is an instrument to measure the development of children aged 1-42 months. Our study sought to assess the feasibility and reliability of the BSID III's cognitive and motor sub-scales among children in rural Nepal.

METHODS

For this study, translation and back translation in Nepali and English for cognitive and motor sub-scale of BSID III were done. Two testers assessed a total of 102 children aged 1-42 months and were video-recorded and rescored by the third tester. Raw scores were calculated for each assessment. Inter and intra-observer reliability of scores across the three testers was examined. Raw score was converted into scaled score to examine the mean score. The study received ethical clearance from NHRC.

RESULTS

A total of 102 children were assessed. The inter-rater reliability of the BSID III among three testers using the Intraclass Correlation Coefficient by age group was 0.997 (95% CI: 0.996-0.998) for the cognitive scale, 0.997 (95% CI: 0.996- 0.998) for the gross motor scale, and 0.998 (95% CI: 0.997- 0.999) for the fine motor scale. All were statistically significant (p< 0.0001). The mean scaled cognitive, fine motor and gross motor development scores in this group of children were 8.3 (SD: 2.5), 8.5 (SD: 2.6) and 9.5 (3.2), respectively.

CONCLUSIONS

Assessing the cognitive and motor development of children under five using the BSID III was feasible in Makwanpur district, Nepal. The inter-rater reliability was highly comparable among the three testers.

Analysis of Health Facility Based Perinatal Verbal Autopsy of Electoral Constituency 2 of Arghakhanchi District, Nepal

BACKGROUND

Verbal autopsy is a method to diagnose possible cause of death by analyzing factors associated with death through detailed questioning. This study is a part of the operational research program in electoral constituency no. 2 (EC 2) of Arghakhanchi district by MIRA and HealthRight International.

METHODS

Two day essential newborn care training followed by one day perinatal verbal autopsy training and later one day refresher verbal autopsy training was given for health staff of EC 2 of Arghakhanchi district in two groups. Stillbirths of >22wks or > 500 gms and Early neonatal deaths (newborns died within7 days of life) were included in this study. The Nepal Government approved verbal autopsy forms were used for performing autopsies. Perinatal deaths were classified according to Wigglesworth's Classification. Causes of Perinatal deaths were analyzed. Data were analyzed in the form of frequencies and tabulation in SPSS 16 .

RESULTS

There were 41 cases of perinatal deaths (PND) were identified. Among them, 37 PNDs were from Arghakhanchi district hospital, 2 PNDs from Thada PHC, and one PND each from Subarnakhal and Pokharathok HPs. Among the 41 PNDs, 26 were stillbirths (SB) and 15 were early neonatal deaths (ENND). The perinatal mortality rate (PMR) of Arghakhanchi district hospital was 32.2 per 1,000 births and neonatal mortality rate (NMR) was 9.8 per 1,000 live births. Out of 26 stillbirths, 54% (14) were fresh SBs and 46% (12) were macerated stillbirths. The most common cause of stillbirth was obstetric complications (47%) where as birth asphyxia (53%) was the commonest cause of ENND. According to Wigglesworth's classification of perinatal deaths, Group IV (40%) was the commonest cause in the health facilities.

CONCLUSIONS

Obstetric complication was the commonest cause of stillbirth and birth asphyxia was the commonest cause of early neonatal death. This study highlighted the need for regular antenatal check-ups and proper intrapartum fetal monitoring with timely and appropriate intervention to reduce the incidence of stillbirths and intrauterine asphyxia.

Maternal and Neonatal Health Knowledge, Service Quality and Utilization: Findings from a Community Based Quasi-experimental Trial in Arghakhanchi District of Nepal

BACKGROUND

As part of the Partnership for Maternal and Newborn Health Project (PMNH), HealthRight International collaborated with Mother and Infant Research Activities (MIRA) to conduct operations research in Arghakhanchi district of Nepal to explore the intervention impact of strengthening health facility, improving community facility linkages along with Community Based Newborn Care Program (CB-NCP) on Maternal Neonatal Care (MNC) service quality, utilization, knowledge and care seeking behavior.

METHODS

This was a quasi-experimental study. Siddahara, Pokharathok, Subarnakhal,Narpani Health Posts (HPs) and Thada Primary Health Care Center(PHCC)in Electoral Constituency-2 were selected as intervention sites and Arghatosh, ,Argha, Khana, Hansapur HPs and Balkot PHCC in Electoral Constituency-1 were chosen as controls. The intervention started in February 2011 and was evaluated in August 2013. To compare MNC knowledge and practice in the community, mothers of children aged 0-23 months were selected from the corresponding Village Development Committees(VDCs) by a two stage cluster sampling design during both baseline (July 2010) and endline (August, 2013) assessments. The difference in difference analysis was used to understand the intervention impact.

RESULTS

Local resource mobilization for MNC, knowledge about MNC and service utilization increased in intervention sites. Though there were improvements, many effects were not significant.

CONCLUSIONS

Extensive trainings followed by reviews and quality monitoring visits increased the knowledge, improved skills and fostered motivation of health facility workers for better MNC service delivery. MNC indicators showed an upsurge in numbers due to the synergistic effects of many interventions.

Analysis of Obstetric Near Miss Cases of Different Health Facilities of Electoral Constituency Two of Arghakhanchi District

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

Biomass fuel use and the exposure of children to particulate air pollution in southern Nepal

The exposure of children to air pollution in low resource settings is believed to be high because of the common use of biomass fuels for cooking. We used microenvironment sampling to estimate the respirable fraction of air pollution (particles with median diameter less than 4 μm) to which 7-9 year old children in southern Nepal were exposed. Sampling was conducted for a total 2649 h in 55 households, 8 schools and 8 outdoor locations of rural Dhanusha. We conducted gravimetric and photometric sampling in a subsample of the children in our study in the locations in which they usually resided (bedroom/living room, kitchen, veranda, in school and outdoors), repeated three times over one year. Using time activity information, a 24-hour time weighted average was modeled for all the children in the study. Approximately two-thirds of homes used biomass fuels, with the remainder mostly using gas. The exposure of children to air pollution was very high. The 24-hour time weighted average over the whole year was 168 μg/m(3). The non-kitchen related samples tended to show approximately double the concentration in winter than spring/autumn, and four times that of the monsoon season. There was no difference between the exposure of boys and girls. Air pollution in rural households was much higher than the World Health Organization and the National Ambient Air Quality Standards for Nepal recommendations for particulate exposure.

Effectiveness of female community health volunteers in the detection and management of low-birth-weight in Nepal

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.

Understanding how women's groups improve maternal and newborn health in Makwanpur, Nepal: a qualitative study

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.

Setting research priorities to reduce global mortality from preterm birth and low birth weight by 2015

AIM

This paper aims to identify health research priorities that could improve the rate of progress in reducing global neonatal mortality from preterm birth and low birth weight (PB/LBW), as set out in the UN's Millennium Development Goal 4.

METHODS

We applied the Child Health and Nutrition Research Initiative (CHNRI) methodology for setting priorities in health research investments. In the process coordinated by the World Health Organization in 2007-2008, 21 researchers with interest in child, maternal and newborn health suggested 82 research ideas that spanned across the broad spectrum of epidemiological research, health policy and systems research, improvement of existing interventions and development of new interventions. The 82 research questions were then assessed for answerability, effectiveness, deliverability, maximum potential for mortality reduction and the effect on equity using the CHNRI method.

RESULTS

The top 10 identified research priorities were dominated by health systems and policy research questions (eg, identification of LBW infants born at home within 24-48 hours of birth for additional care; approaches to improve quality of care of LBW infants in health facilities; identification of barriers to optimal home care practices including care seeking; and approaches to increase the use of antenatal corticosteriods in preterm labor and to improve access to hospital care for LBW infants). These were followed by priorities for improvement of the existing interventions (eg, early initiation of breastfeeding, including feeding mode and techniques for those unable to suckle directly from the breast; improved cord care, such as chlorhexidine application; and alternative methods to Kangaroo Mother Care (KMC) to keep LBW infants warm in community settings). The highest-ranked epidemiological question suggested improving criteria for identifying LBW infants who need to be cared for in a hospital. Among the new interventions, the greatest support was shown for the development of new simple and effective interventions for providing thermal care to LBW infants, if KMC is not acceptable to the mother.

CONCLUSION

The context for this exercise was set within the MDG4, requiring an urgent and rapid progress in mortality reduction from low birth weight, rather than identifying long-term strategic solutions of the greatest potential. In a short-term context, the health policy and systems research to improve access and coverage by the existing interventions, coupled with further research to improve effectiveness, deliverability and acceptance of existing interventions, and epidemiological research to address the key gaps in knowledge, were all highlighted as research priorities.

Analysis of perinatal deaths and ascertaining perinatal mortality trend in a hospital

BACKGROUND

Perinatal mortality rate is very high in developing countries including Nepal. Analyzing perinatal deaths help in identifying preventable factors thus help in reducing it. Analysis of causes of perinatal deaths over a period in a hospital will help to identify the perinatal mortality trend and preventable factors thus help in taking corrective measures to reduce the perinatal mortality rate. The aim of the study is to analyse perinatal deaths and ascertain perinatal mortality trend of Kathmandu Medical College Teaching hospital in the last 8 year period.

METHODS

Stillbirths and early neonatal deaths from 2002 to 2011 are collected from the register book of the labour room, special care baby unit and operation theatre of the hospital. Perinatal mortality rate and extended perinatal mortality rates are calculated and perinatal deaths were classified according to Wigglesworth's classification. Trend of Perinatal and Extended Perinatal mortality rates, stillbirth rates and early neonatal death rates among 5 perinatal death audits of the hospital were compared.

RESULTS

In the first perinatal death audit (Oct '02-Sept '03) perinatal mortality rate (PMR) was recorded as 30.7 per 1000 births and extended perinatal mortality rate (EPMR) as 47.9 per 1000 births, where as in the fifth perinatal death audit (Apr '10-Mar '11) PMR was recorded as 14.4 per 1000 births and EPMR as 19.6 per 1000 births. In Wigglesworth's classification, in the first perinatal death audit, most of the perinatal deaths were in group IV (41%) reflecting more asphyxial deaths however in fifth audit, group III mortality (41%) was highest indicating death of low birth weight or preterm babies. In the first audit, stillbirth rate (SBR) excluding <1 kg was 18.1 per 1000 births and early neonatal deaths (ENND) excluding <1 kg was 12.9 per 1000 live births. In the fifth audit, SBR (excluding <1 kg) and ENND rate (excluding <1 kg) were 7.1 per 1000 births and 7.2 per 1000 live births respectively reflecting declining trend of both SBR and ENND rate in the hospital.

CONCLUSIONS

Distinct declining trend in PMR, EPMR, SBR and ENND rates at KMCTH were noted. As asphyxial deaths have been reduced significantly, more intensive efforts are needed to prevent premature births with care of preterm and very low birth weight babies.

Causes of stillbirths and neonatal deaths in Dhanusha district, Nepal: a verbal autopsy study

BACKGROUND

Perinatal (stillbirths and first week neonatal deaths) and neonatal (deaths in the first 4 weeks) mortality rates remain high in developing countries like Nepal. As most births and deaths occur in the community, an option to ascertain causes of death is to conduct verbal autopsy.

OBJECTIVE

The objective of this study was to classify and review the causes of stillbirths and neonatal deaths in Dhanusha district, Nepal.

MATERIALS AND METHODS

Births and neonatal deaths were identified prospectively in 60 village development committees of Dhanusha district. Families were interviewed at six weeks after delivery, using a structured questionnaire. Cause of death was assigned independently by two pediatricians according to a predefined algorithm; disagreement was resolved in discussion with a consultant neonatologist.

RESULTS

There were 25,982 deliveries in the 2 years from September 2006 to August 2008. Verbal autopsies were available for 601/813 stillbirths and 671/954 neonatal deaths. The perinatal mortality rate was 60 per 1000 births and the neonatal mortality rate 38 per 1000 live births. 84% of stillbirths were fresh and obstetric complications were the leading cause (67%). The three leading causes of neonatal death were birth asphyxia (37%), severe infection (30%) and prematurity or low birth weight (15%). Most infants were delivered at home (65%), 28% by relatives. Half of women received an injection (presumably an oxytocic) during home delivery to augment labour. Description of symptoms commensurate with birth asphyxia was commoner in the group of infants who died (41%) than in the surviving group (14%).

CONCLUSION

The current high rates of stillbirth and neonatal death in Dhanusha suggest that the quality of care provided during pregnancy and delivery remains sub-optimal. The high rates of stillbirth and asphyxial mortality imply that, while efforts to improve hygiene need to continue, intrapartum care is a priority. A second area for consideration is the need to reduce the uncontrolled use of oxytocic for augmentation of labour.

Erratum to "Maternal, neonatal and child health interventions and services: moving from knowledge of what works to systems that deliver" [International Health 2 (2010) 87-98]

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.

How did formative research inform the development of a women's group intervention in rural Nepal?

Inability to reduce neonatal and maternal mortality in poor countries is sometimes blamed on a lack of contextual knowledge about care practices and care-seeking behavior. There is a lack of knowledge about how to translate formative research into effective interventions to improve maternal and newborn health. We describe the findings of formative research and how they were used to inform the development of such an intervention in rural Nepal. Formative research was carried out in four parts. Part 1 involved familiarization with the study area and literature review, and parts 2, 3 and 4 involved community mapping, audit of health services, and qualitative and quantitative studies of perinatal care behaviors. Participatory approaches have been successful at reducing neonatal mortality and may be suitable in our context. Community mapping and profiling helped to describe the community context, and we found that community-based organizations often sought to involve the Female Community Health Volunteer in community mobilization. She was not routinely conducting monthly meetings and found them difficult to sustain without support and supervision. In health facilities, most primary care staff were in post, but doctors and staff nurses were absent from referral centers. Mortality estimates reflected under-reporting of deaths and hygiene and infection control strategies had low coverage. The majority of women give birth at home with their mother-in-law, friends and neighbors. Care during perinatal illness was usually sought from traditional healers. Cultural issues of shyness, fear and normalcy restricted women's behavior during pregnancy, birth and the postpartum period, and decisions about her health were usually made after communications with the family and community. The formative research indicated the type of intervention that could be successful. It should be community-based and should not be exclusively for pregnant women. It should address negotiations within families, and should tailor information to the needs of local groups and particular stakeholders such as mothers-in-law and traditional healers. The intervention should not only accept cultural constructs but also be a forum in which to discuss ideas of pollution, shame and seclusion. We used these guidelines to develop a participatory, community-based women's group intervention, facilitated through a community action cycle. The success of our intervention may be because of its acceptability at the community level and its sensitivity to the needs and beliefs of families and communities.

Two year audit of perinatal mortality at Kathmandu Medical College Teaching Hospital

INTRODUCTION

Perinatal mortality rate is a sensitive indicator of quality of care provided to women in pregnancy, at and after child birth and to the newborns in the first week of life. Regular perinatal audit would help in identifying all the factors that play a role in causing perinatal deaths and thus help in appropriate interventions to reduce avoidable perinatal deaths.

AIMS AND OBJECTIVES

This study was carried out to determine perinatal mortality rate (PMR) and the factors responsible for perinatal deaths at KMCTH in the two year period from November 2003 to October 2005 (Kartik 2060 B.S. to Ashoj 2062).

METHODOLOGY

This is a prospective study of all the still births and early neonatal deaths in KMCTH during the two year period from November 2003 to October 2005. Details of each perinatal death were filled in the standard perinatal death audit forms of the Department of Pediatrics, KMCTH. Perinatal deaths were analyzed according to maternal characteristics like maternal age, parity, type of delivery and fetal characteristics like sex, birth weight and gestational age and classify neonatal deaths according to Wigglesworth's classification and comparison made with earlier similar study.

RESULTS

Out of the 1517 total births in the two year period, 22 were still births (SB) and 10 were early neonatal deaths (ENND). Out of the 22 SB, two were of < 1 kg in weight and out of 10 ENND, one was of <1 kg. Thus, perinatal mortality rate during the study period was 19.1 and extended perinatal mortality rate was 21.1 per 1000 births. The important causes of perinatal deaths were extreme prematurity, birth asphyxia, congenital anomalies and associated maternal factors like antepartum hemorrhage and most babies were of very low birth weight. According to Wigglesworth's classification, 43.8% of perinatal deaths were in Group I, 12.5% in Group II, 28.1% in Group III, 12.5% in Group IV and 12.5% in Group V.

DISCUSSION

The perinatal death audit done in KMCTH for 1 year period from September 2002 to August 2003 showed perinatal mortality rate of 30.7 and extended perinatal mortality rate of 47.9 per 1000 births. There has been a significant reduction in the perinatal mortality rate in the last 2 years at KMCTH. Main reasons for improvement in perinatal mortality rate were improvement in care of both the mothers and the newborns and the number of births have also increased significantly in the last 2 years without appropriate increase in perinatal deaths.

CONCLUSION

Good and regular antenatal care, good care at the time of birth including appropriate and timely intervention and proper care of the sick neonates are important in reducing perinatal deaths. Prevention of preterm births, better care and monitoring during the intranatal period and intensive care of low birth weight babies would help in further reducing perinatal deaths. Key words: Perinatal mortality rate (PMR), still births, early neonatal death (ENND), Total perinatal death (PND).

Hemoglobin status in children in the age group 6 to 60 months

Objective of this study was to see the prevalence rate of anemia in children among the age of 6-60 months who attended paediatric out patient department of Kathmandu Medical College. 100 children aged 6-60 months were randomly selected for hemoglobin measurement and anthropometry. Detailed clinical examination including anthropometry was done. Hemoglobin was checked by Hemocue machine with prior consent from the attendant. Mean height, weight, and body mass index (BMI) were measured. Forty six percent of the study group population had hemoglobin <11 gm/dl, similar numbers of the children were in the various state of malnutrition. Twenty eight percent of the children came from outside of the valley residing in Kathmandu. Fifty percent were illiterate or had primary level education only. Poverty, high rate of illiteracy and lack of awareness on taking appropriate food were important factors related to such a high childhood anemia. Iron supplementation should be given to the children particularly in the age group of 6 months to 3 years.

Prevalence of childhood and adolescent disabilities in rural Nepal

The study aimed to determine the number of children and young people reported as having a disability by family members, and to classify impairments leading to disability. A Cross-sectional census was conducted of all households in 24 rural geopolitical units of Makwanpur district, Nepal. Heads of household were asked about family members under the age of 20 with disability. Such members were resident in 733 of 28,376 households, a household prevalence of 2.58%. 829 people under the age of 20 were reported as having a disability, a population prevalence of 0.95%. The commonest functional impairments reported were motor and the commonest anatomical impairments involved the limbs. More males with disability were identified than females.

One year follow up study of term babies born at Kathmandu medical college teaching hospital

OBJECTIVE

To study the mean, standard deviation and centiles for anthropometry and haemoglobin in healthy term infants followed up to 12 months of age.

DESIGN

Cohort study.

SETTINGS

Kathmandu Medical College Teaching Hospital (KMCTH) in Kathmandu.

SUBJECT

Consecutive healthy term newborns Method: 100 consecutive healthy term newborns were enrolled at birth.19 babies were lost in follow up. So, 81(45 male, 36 female) healthy, full term infants were followed up from birth to 12 months of age. Anthropometry (weight, length, and head circumference) and haemoglobin were measured at birth, 6 weeks, 6 months, 9 months and 12 months of age. Haemoglobin was estimated by Hemocue microcuvette method. The data so obtained was subjected to statistical analysis by using SPSS computer package.

MAIN OUTCOMES

Mean, centile and standard deviation score values for weight (Kgs), infant length (cms), head circumference (cms) and haemoglobin (gm/dl) at birth, 6 weeks, 6 months, 9 months and 12 months of age.

RESULTS

Out of 100 babies enrolled, data presented here is for the remaining 81 babies. Among 81 babies, 76 were appropriate for gestational age (AGA) and 3 were small for gestation (SFD). The mean, standard deviation and percentile values are presented for anthropometry (weight, length and head circumference) and haemoglobin at birth, 6 weeks, 6 months, 9 months and 12 months of age. The mean birth weight was 3.05 kg (SD 0.41). The mean infant length and head circumference at birth were 49 cm (2.28) and 33.8 cm (SD1.4) respectively. The mean haemoglobin at birth was 15.7 gm/dl (SD 2.29). At 12 months of age mean weight, length, head circumference and haemoglobin were 9 kg (SD 0.81), 73.5 cm (SD 2.9), 45 cm (SD 1.2 ) and 11.1 gm/dl (SD 1.41) respectively. Almost 50% of the babies at 6 weeks, 9 months and 12 months of age were found to be anaemic (Hb < 11 gm/dl). Among the babies, 49% were exclusively breast fed for 6 months of age. Other feeding practices seen were, mothers breast feed with water supplementation (25%), mothers breast feeding with formula feed (16%) and formula feeding only (5%). National and international comparisons of anthropometry and haemoglobin data are shown in table.

Perinatal death audit

Perinatal mortality rate (PMR), which indicates quality of care provided to women in pregnancy, at and after child birth and to the newborns in the first week of life, is high in Nepal. Published results show wide variation in PMR in the country. Higher rates are in the community and hospitals outside Kathmandu. Reduction of PMR is an important strategy in improving maternal and neonatal health and requires identification of factors related to perinatal deaths. Perinatal death audit is a process of assessing factors related to a perinatal death. It helps in reducing perinatal mortality by identifying preventable factors related to perinatal deaths. Classifying perinatal deaths into 5 groups of Wigglesworth helps in identifying major obstetric or neonatal factors related perinatal deaths. Major factors related to perinatal deaths in Nepal are poor antenatal care, poor monitoring and assistance at birth and lack of adequate neonatal care services. Regular perinatal audit would identify factors and lapses related to perinatal deaths and thus help in taking appropriate interventions to reduce avoidable perinatal deaths.

Salivary cortisol and heart rate in stunted and nonstunted Nepalese school children

OBJECTIVE

To test the hypothesis that stunted Nepalese children have an altered stress response system when compared with matched nonstunted children in response to a battery of psychological tests.

DESIGN

Case-control study.

SETTING

Poor urban areas of Kathmandu, Nepal.

SUBJECTS

A total of 64 stunted (less than -2 s.d. height-for-age) children compared with 64 nonstunted (> -1s.d. height-for-age) schoolchildren between 8 and 10 y old matched for school and sex.

METHODS

A psychological test session was administered, which included mental arithmetic and two tests of working memory. Salivary cortisol samples were obtained at five points during testing, and heart rate was measured during testing and also at baseline. Salivary cortisol samples were also obtained once early in the morning. Hemoglobin was assessed at the testing session, and extensive data were obtained on the social background of the children's families.

RESULTS

Stunted Nepalese children showed a blunted physiologic response (salivary cortisol and heart rate) to psychological stressors (P<0.05) when compared with nonstunted children, but were not different from the nonstunted children in baseline measures, when controlling for social background. The two groups were not different in terms of social background.

CONCLUSIONS

These findings suggest that childhood growth retardation may be associated with changes in physiological arousal, and that stunting could be associated with hyporesponsivity in response to psychological stress.

Low Cost Level II Newborn Care Service: Experience Of Kathmandu Medical College Teaching Hospital

Newborn infants require special care when they become sick. Majority of the newborn require only feeding,warmth and loving care by the mothers. Nearly 15-20% of newborns become sick requiring care in hospital.Most of these babies can be managed using low cost locally made equipment which makes newborn careaffordable. This is a prospective study of 201 sick newborns looked after in the Special Care Baby Unit(SCBU) of Kathmandu Medical College Teaching Hospital (KMCTH) using locally made low cost equipment.In the period of 28 months from 2nd July, 2001 to 17th Oct. 2003, 882 babies were delivered at KathmanduMedical College Teaching Hospital (KMCTH). 859 were live births. Out of 859 live births, 173 (20.1%)were admitted in the special care baby unit (SCBU). SCBU of this hospital also admitted 28 babies bornoutside the hospital. The main causes of admission in SCBU were low birth weight (37.3%), neonataljaundice (18.9%), birth asphyxia (6.9%), septicaemia (2.4%) and out of 201 babies admitted in SCBU,89% were discharged in good condition, 3.9% of the babies left against medical advice, 2 babies (one withcongenital hydronephrosis and another with congenital hypertrophic pyloric stenosis) were transferred toKanti Children Hospital for surgery and 11 babies (5.4%) expired. The main causes of neonatal deathswere extreme prematurity (70%), septicaemia (23%), birth asphyxia (15.3%) and congenital anomalies(7.6%). The perinatal mortality rate (PMR) and neonatal mortality rate (NMR) during this period were26.4/1000 births and 15.1/1000 live births respectively. In SCBU, locally made low cost equipment(Resuscitaire, Warm cot, Phototherapy and Oxygen hood designed by Prof D.S. Manandhar) are beingused in the manangement of sick babies, since the unit was started on 2nd July, 2001. Babies with birthweight as low as 1020 gms and gestation as low as 28 weeks have survived in this unit. This unit has shownthat Level II care could be provided with simple and low cost equipment and results are quite satisfactory.Good antenatal care, good care during delivery including use of partogram and care during postnatalperiod have helped to make this result good. Expansion of such facilities in district and bigger hospitals inthe country are not only affordable but also will have great impact in saving many lives. This will have amajor impact in reducing the present high IMR and NMR of the country.Key Words: Care of sick neonates, low cost locally made equipment, common neonatal problems,special care baby unit, and level II care.

CAN WE MANAGE NEONATAL INFECTION IN THE COMMUNITY ?

As infant mortality rates have fallen in many developing countries, the problem of neonatal mortality hasbecome more obvious. The biggest causes of mortality in the first month of life are infection, birth asphyxia,and low birth weight. Infection is implicated in about a third of neonatal deaths in Nepal. Communitybaseddata are limited, but neonatal sepsis is likely to be the result of infection by Gram positive bacteriasuch as Staphylococci and Streptococci, and enteric Gram negatives.The appropriate management for neonatal sepsis is parenteral, hospital-based treatment with a penicillinand an aminoglycoside. However, about 90% of births in Nepal take place at home, and many infants neverreach hospital. For these infants, the next best management strategy is to give parenteral antibiotics at aprimary care facility. Before referral, it would be appropriate to give a dose of oral antibiotic such ascotrimoxazole, which is already incorporated into the acute respiratory infection programme. If referralfor parenteral treatment is not successful, we propose that community-based cadres be allowed to give a fullcourse of oral antibiotic in cases of neonatal sepsis.Community health workers should receive training and pictorial guidelines for the recognition of dangersigns for neonatal sepsis, and we recommend pilot studies to compare and evaluate oral treatment in thecommunity. For Nepal, a national policy on the community management of neonatal infection is an extremelyurgent priority.Key Words: Neonatal infection, community management, antibiotic use.

A case report of Gilbert Syndrome

Gilbert syndrome is benign, often familial condition characterized by recurrent but asymptomatic mild unconjugated hyperbilirubinemia in the absence of haemolysis or underlying liver disease. If, it becomes apparent, it is not until adolescence and then usually in association with stress such as intercurrent illness, fasting or strenuous exercise. Virtually all patients have decreased level of UDP-Glucuronosyltransferase, but there also is evidence for a defect in hepatic uptake of bilirubin as well. This case is reported due to its rarity. The prevalence of Gilbert syndrome in U.S is 3-7% of the population.

Reye's syndrome

Five and half years male child with one day history of pain abdomen and vomiting who was on aspirin for suspected rheumatoid arthritis presented initially with acute gastritis. Next day, however he developed the signs of encephalopathy with altered liver function.

DESIGN OF A SURVEILLANCE SYSTEM FOR PREGNANCY AND ITS OUTCOMES IN RURAL NEPAL

IntroductionCommunity trials in low-income countries require monitoring and evaluation systems.The requirements of a community surveillance system include coherent design, training,field supervision and reporting, as well as the need for a robust and flexible database.Materials and methodsThis paper describes a surveillance system for identification of pregnancy and itsoutcomes in a rural area of Nepal. Mother Infant Research Activities (MIRA), incollaboration with the Institute of Child Health, London, are presently conducting astudy on the impact of a community-based participatory intervention to improveessential newborn care (ENC) in rural Nepal. The study is a cluster randomisedcontrolled trial involving 12 pairs of Village Development Committees (VDCs) inMakwanpur District. The surveillance system covers approximately 28 000 householdsand 28 000 married women of reproductive age. It was designed to identify pregnancy,its outcome for mother and infant, and activities such as antenatal care and problem-related health care seeking behaviour.DiscussionThe paper describes the processes of mapping and enumeration, pregnancyidentification, conduct of interviews, quality control and data management.Key Words: data quality, database, rural Nepal.

A case report of Wilson's disease

Wilson's disease (hepatolenticuler degeneration), an inborn error of copper metabolism, is an autosomal recessive disorder characterized by degenerative changes in brain, liver disease and Kayser Fleisher (KF) rings in the cornea. It is due to a defect of p-type ATPase which is probably required for normal extrusion of copper from cells. In this case report, we present a seven and half year old male who presented with complaints of slurring of speech, drooling of saliva, intentional tremor and dark pigmentation over face and trunk for last 9 months. On examination KF ring was present, spleen was palpable and intentional tremor was present. Laboratory investigations confirmed the diagnosis.

Clinical predictors of outcome following mild and moderate neonatal encephalopathy in term newborns in Kathmandu, Nepal

We describe a clinical grading system for the assessment of neonatal encephalopathy developed for a large prospective study in Kathmandu. Inter-observer variability testing of our system on 27 infants showed high agreement (kappa value 0.87). Validity for the prediction of major neurodevelopmental impairment at 1 y of age was tested using a cohort of 57 survivors of encephalopathy, all of whom were assessed using a combination of the Denver Developmental Screening Test and Bailey 2 at 1 y. We compared this with a modification of a scoring system previously validated in Cape Town. Both schemes converted a pretest probability of 31% (the prevalence of major impairment at 1 y of age in this cohort) to a post-test probability of 55%. This showed only marginal improvement over the traditional risk marker of neurological abnormality at discharge (post-test probability 51%). At 6 wk of age acquired microcephaly increased the probability of major impairment to 79%.

CONCLUSIONS

It seems to make little difference both in practical or predictive terms whether one describes the neurological condition of the neonate using a descriptive or scoring system. The important thing is to perform repeated systematic neurological examinations on a daily basis during the neonatal period. Many clinicians will justifiably continue to use the discharge examination as the deciding factor for the need for continued neurodevelopmental surveillance.

Risk factors for neonatal encephalopathy in Kathmandu, Nepal, a developing country: unmatched case-control study

OBJECTIVE

To determine the risk factors for neonatal encephalopathy among term infants in a developing country.

DESIGN

Unmatched case-control study.

SETTING

Principal maternity hospital of Kathmandu, Nepal.

SUBJECTS

All 131 infants with neonatal encephalopathy from a population of 21 609 infants born over an 18 month period, and 635 unmatched infants systematically recruited over 12 months.

MAIN OUTCOME MEASURES

Adjusted odds ratio estimates for antepartum and intrapartum risk factors.

RESULTS

The prevalence of neonatal encephalopathy was 6.1 per 1,000 live births of which 63% were infants with moderate or severe encephalopathy. The risk of death from neonatal encephalopathy was 31%. The risk of neonatal encephalopathy increased with increasing maternal age and decreasing maternal height. Antepartum risk factors included primiparity (odds ratio 2.0) and non-attendance for antenatal care (2.1). Multiple births were at greatly increased risk (22). Intrapartum risk factors included non-cephalic presentation (3.4), prolonged rupture of membranes (3.8), and various other complications. Particulate meconium was strongly associated with encephalopathy (18). Induction of labour with oxytocin was associated with encephalopathy in 12 of 41 deliveries (5.7). Overall, 78 affected infants (60%) compared with 36 controls (6%) either had evidence of intrapartum compromise or were born after an intrapartum difficulty likely to result in fetal compromise. A concentration of maternal haemoglobin of less than 8.0 g/dl in the puerperium was significantly associated with encephalopathy (2.5) as was a maternal thyroid stimulating hormone concentration greater than 5 mIU/l (2.1).

CONCLUSIONS

Intrapartum risk factors remain important for neonatal encephalopathy in developing countries. There is some evidence of a protective effect from antenatal care. The use of oxytocin in low income countries where intrapartum monitoring is suboptimal presents a major risk to the fetus. More work is required to explore the association between maternal deficiency states and neonatal encephalopathy.

Neonatal hypoglycaemia in Nepal 1. Prevalence and risk factors

AIMS

To measure the prevalence of hypoglycaemia among newborn infants in Nepal, where classic risk factors prevail, and to evaluate their importance.

METHODS

A cross sectional study was done of 578 term newborn infants aged 0 to 48 hours on the postnatal wards of a government maternity hospital in Kathmandu, with unmatched case-control analysis of risk factors for moderate hypoglycaemia (less than 2.0 mmol /l).

RESULTS

Two hundred and thirty eight (41%) newborn infants had mild (less than 2.6 mmol/l) and 66 (11%) moderate hypoglycaemia. Significant independent risk factors for moderate hypoglycaemia included postmaturity (OR 2.62), birthweight under 2.5 kg (OR 2.11), small head size (OR 0.59), infant haemoglobin >210 g/l (OR 2.77), and raised maternal thyroid stimulating hormone (TSH) (OR 3.08). Feeding delay increased the risk of hypoglycaemia at age 12-24 hours (OR 4.09). Disproportionality affected the risk of moderate hypoglycaemia: lower with increasing ponderal index (OR 0.29), higher as the head circumference to birthweight ratio increased (OR 1.41). Regression expressing blood glucose concentration as a continuous variable revealed associations with infant haemoglobin (negative) and maternal haemoglobin (positive), but no other textbook risk factors.

CONCLUSIONS

Neonatal hypoglycaemia is more common in a developing country, but may not be a clinical problem unless all fuel availability is reduced. Some textbook risk factors, such as hypothermia, disappear after controlling for confounding variables. Early feeding could reduce moderate hypoglycaemia in the second 12 hours of life. The clinical significance of raised maternal TSH and maternal anaemia as prenatal risk factors requires further research.

Stillbirths and neonatal encephalopathy in Kathmandu, Nepal: an estimate of the contribution of birth asphyxia to perinatal mortality in a low-income urban population

We describe a prospective cross-sectional survey over a 12-month period in the principal maternity hospital of Kathmandu, Nepal, where over 50% of the local population deliver. The study aim was to estimate the contribution of birth asphyxia to perinatal mortality in this setting. During 1995, there were 14,371 livebirths and 400 stillbirths, a total stillbirth rate of 27 per 1000 total births. The fresh term (2000 g or more) stillbirth rate was 8.5 per 1000 total births [95% CI 7.1, 10.1]. Ninety-two cases of neonatal encephalopathy (NE) affecting term infants were detected (excluding those due to congenital malformations, hypoglycaemia and early neonatal sepsis). The birth prevalence of NE was 6.4 per 1000 livebirths [95% CI 5.2, 7.8]. There was evidence of intrapartum compromise in 63 (68%) of the cases of NE and 65 (76%) of the stillbirths, but only in 12 (12%) of controls. The cause-specific early neonatal mortality rate for NE was 2.1 per 1000 livebirths [95% CI 1.4, 3.0]. Combining the NE deaths and fresh stillbirths gives an upper estimate for term birth asphyxia perinatal mortality rate of 10.8 per 1000 total births [95% CI 9.2, 12.6], 24% of all perinatal deaths before hospital discharge. This study suggests that birth asphyxia remains an important cause of perinatal mortality in developing countries. The paper discusses the pros and cons of different strategies to reduce birth asphyxia in low-income countries.

Neonatal hypoglycaemia in Nepal 2. Availability of alternative fuels

AIMS

To study early neonatal metabolic adaptation in a hospital population of neonates in Nepal.

METHODS

A cross sectional study was made of 578 neonates, 0 to 48 hours after birth, in the main maternity hospital in Kathmandu. The following clinical and nutritional variables were assessed: concentrations and age profiles of blood glucose, hydroxybutyrate, lactate, pyruvate, free fatty acids (FFA) and glycerol; associations between alternative fuel levels and hypoglycaemia; and regression of possible risk factors for ketone availability.

RESULTS

Risk factors for impaired metabolic adaptation were common, especially low birthweight (32%), feeding delays, and cold stress. Blood glucose and ketones rose with age, but important age effects were also found for risk factors like hypothermia, thyroid hormone activities, and feeding practices. Alternative fuel concentrations, except FFA, were significantly reduced in infants with moderate hypoglycaemia during the first 48 hours after birth. Unlike earlier studies, small for gestational age (SGA) infants had significantly higher hydroxybutyrate:glucose ratios which suggested counter regulatory ketogenesis. Hypoglycaemic infants were not hyperinsulinaemic. Regression analysis showed risk factors for impaired counter regulation which included male and large infants, hypothermia, and poorer infant thyroid function. SGA infants and those whose mothers had received no antenatal care had increased counter regulation.

CONCLUSIONS

Alternative fuels are important in the metabolic assessment of neonates, and they might provide effective cerebral metabolism even during moderate hypoglycaemia. Hypoglycaemic infants generally had lower concentrations of alternative fuels through either reduced availability or increased consumption. SGA and post term infants increased counter regulatory ketogenesis with early neonatal hypoglycaemia, but hypothermia, male gender, and low infant T4 were associated with impaired counter regulation after birth.

Outcome at 1 year of neonatal encephalopathy in Kathmandu, Nepal

To determine the outcome at 1 year of neonatal encephalopathy (NE) and to estimate the possible contribution of birth asphyxia to childhood disability in a low-income South Asian country, a prospective cohort study was undertaken in the principal maternity hospital of Kathmandu, where over 50% of local women give birth. From a total population cohort of 21609 live births, 131 term infants with NE (after exclusion of cases associated with neonatal sepsis, congenital malformations, or primary hypoglycaemia) and 208 term control infants were recruited. Of these, 102 (78%) infants with NE and 106 (51%) control infants were followed-up to 1 year of age. Outcome measures were death or neurodevelopmental impairment, graded as major, minor or none. Of the 131 term infants with NE, 83 were graded with moderate or severe NE according to conventional definition. By 1 year of age, 45 (44%) of the infants with NE had died, 18 (18%) had severe impairments, and two (2%) had minor impairments; four (4%) of the control subjects had died and two (2%) had minor impairments. Most deaths in subjects with NE occurred in the early neonatal period; NE carried no excess risk of death beyond the neonatal period. Of the 18 children with major impairment, 14 (78%) had spastic tetraplegic cerebral palsy and eight (44%) had multiple impairments. Compared with the control group the relative risk of death by 1 year was 5 (95% CI 1.4 to 15) for mild NE, 8 (95% CI 3 to 23) for moderate, and 26 (95% CI 10 to 67) for severe. Twenty-seven of 38 (71%) infants with moderate NE either died or survived with major impairment. An upper estimate for the prevalence of major neuroimpairment at 1 year attributable to birth asphyxia is 1 per 1000 live births in this population.

Factors affecting home delivery in the Kathmandu Valley, Nepal

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.

An Apgar score of three or less at one minute is not diagnostic of birth asphyxia but is a useful screening test for neonatal encephalopathy

OBJECTIVE

To evaluate the relationship between an Apgar score of three or less at one minute of life and the subsequent risk of developing neonatal encephalopathy (NE).

DESIGN

Prospective.

SETTING

The principal maternity hospital of Kathmandu, Nepal, a low income country, where over 50% of the local population deliver.

METHODS

All liveborn infants over a 12 month period with a birthweight of 500 g or more were assessed by the Apgar scoring system at one minute of age. All term infants with neurological abnormalities presenting in the first day of life were systematically examined and described according to a conventionally defined encephalopathy grading system. Major congenital malformations and neonatal infections were excluded.

RESULTS

Over 12 months there were 14,771 total births of a weight of 500 g or more of which 14,371 were live births and 400 were stillbirths. Of 734 infants with 1 min Apgar of three or less, 91 developed NE. The positive and negative predictive values of 1 min Apgar of three or less for NE were 11.4% and 99.9%, respectively. The probability of developing NE rose from 0.6% (amongst all infants born at this hospital) to 11.2% (amongst infants born with a one minute Apgar of three or less).

CONCLUSIONS

An Apgar score of 3 or less at one minute is a useful screening test for clinically significant birth asphyxia (NE). It overestimates by eight fold the scale of the birth asphyxia problem, but identifies a high risk group requiring further observation of their neurological condition.

The effects of postnatal health education for mothers on infant care and family planning practices in Nepal: a randomised controlled trial

OBJECTIVES

To evaluate impact of postnatal health education for mothers on infant care and postnatal family planning practices in Nepal.

DESIGN

Randomised controlled trial with community follow up at 3 and 6 months post partum by interview. Initial household survey of study areas to identify all pregnant women to facilitate follow up.

SETTING

Main maternity hospital in Kathmandu, Nepal. Follow up in urban Kathmandu and a periurban area southwest of the city.

SUBJECTS

540 mothers randomly allocated to one of four groups: health education immediately after birth and three months later (group A), at birth only (group B), at three months only (group C), or none (group D).

INTERVENTIONS

Structured baseline household questionnaire; 20 minute, one to one health education at birth and three months later.

MAIN OUTCOME MEASURES

Duration of exclusive breast feeding, appropriate immunisation of infant, knowledge of oral rehydration solution and need to continue breast feeding in diarrhoea, knowledge of infant signs suggesting pneumonia, uptake of postnatal family planning.

RESULTS

Mothers in groups A and B (received health education at birth) were slightly more likely to use contraception at six months after birth compared with mothers in groups C and D (no health education at birth) (odds ratio 1.62, 95% confidence interval 1.06 to 2.5). There were no other significant differences between groups with regards to infant feeding, infant care, or immunisation.

CONCLUSIONS

Our findings suggest that the recommended practice of individual health education for postnatal mothers in poor communities has no impact on infant feeding, care, or immunisation, although uptake of family planning may be slightly enhanced.

Liquid crystal thermometry for the detection of neonatal hypothermia in Nepal

We assessed the sensitivity, specificity and likelihood ratio of a low cost liquid crystal strip thermometer (LCT) compared with axillary mercury thermometry for the detection of neonatal hypothermia in Nepal. The subjects were 76 healthy newborns in the government maternity hospital of Kathmandu, Nepal in winter. The validity of LCT for the detection of neonatal hypothermia (less than 36 degrees C) showed a sensitivity of 83 per cent, specificity 96 per cent, positive predictive value 98 per cent and a likelihood ratio of 23. Use of LCT on newborns in this setting raises a measured pretest probability of first day hypothermia of 63 per cent to a post-test probability of 97 per cent. Liquid crystal thermometry is a simple, low-cost, and valid method for identifying core hypothermia in newborns. It is ideal for isolated rural communities where LCT strips could be added to delivery kits.

Comparison of two cotside methods for the detection of hypoglycaemia among neonates in Nepal

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%.

Postnatal hypothermia and cold stress among newborn infants in Nepal monitored by continuous ambulatory recording

AIMS

To describe the pattern of hypothermia and cold stress after delivery among a normal neonatal population in Nepal; to provide practical advice for improving thermal care in a resource limited maternity hospital.

METHODS

The principal government funded maternity hospital in Kathmandu, Nepal, with an annual delivery rate of 15,000 (constituting 40% of all Kathmandu Valley deliveries), severe resource limitations (annual budget Pounds 250,000), and a cold winter climate provided the setting. Thirty five healthy term neonates not requiring special care were enrolled for study within 90 minutes of birth. Continuous ambulatory temperature monitoring, using microthermistor skin probes for forehead and axilla, a flexible rectal probe, and a black ball probe placed next to the infant for ambient temperature, was carried out. All probes were connected to a compact battery powered Squirrel Memory Logger, giving a temperature reading to 0.2 degree C at five minute intervals for 24 hours. Severity and duration of hypothermia, using cutoff values of core temperature less than 36 degrees C, 34 degrees C, and 32 degrees C; and cold stress, using cutoff values of skin-core (forehead-axilla) temperature difference greater than 3 degrees C and 4 degrees C were the main outcome measures.

RESULTS

Twenty four hour mean ambient temperatures were generally lower than the WHO recommended level of 25 degrees C (median 22.3 degrees C, range 15.1-27.5 degrees C). Postnatal hypothermia was prolonged, with axillary core temperatures only reaching 36 degrees C after a mean of 6.4 hours (range 0-21.1; SD 4.6). There was persistent and increasing cold stress over the first 24 hours with the core-skin (axillary-forehead) temperature gap exceeding 3 degrees C for more than half of the first 24 hours.

CONCLUSIONS

Continuous ambulatory recording identifies weak links in the "warm chain" for neonates. The severity and duration of thermal problems was greater than expected even in a hospital setting where some of the WHO recommendations had already been implemented.

Prevalence of congenital adrenal hyperplasia in Kuwait

Between 1978 and 1988 congenital adrenal hyperplasia (CAH) was diagnosed in 60 children in Kuwait with an estimated prevalence of 1:9,000 livebirths, which is higher than that reported from Europe and Canada. In addition, there was presumptive evidence of CAH resulting in the death of 20 other children, giving a prevalence figure of 1:7000. There were 41 girls (68%) and 19 boys (32%). Thirty-one of the girls (75.6%) and 11 of the boys (57.9%) were saltlosers. Fifty-four patients (90%) were diagnosed as 21-hydroxylase deficient, 3 patients (5%) had a deficiency of the 3 beta-hydroxy-steroid dehydrogenase enzyme, and 3 patients (5%) showed a deficiency of 11 beta-hydroxylase.

Rickets with alopecia-remission following a course of 1-alpha-hydroxy vitamin D3 therapy

A child is described with rickets and alopecia who did not respond to high doses of vitamin D3 but who responded to a small dose of 1-alpha-hydroxyvitamin D3. Treatment was continued for 2 years and then stopped. She has not shown any signs of relapse 1 year after stopping treatment. Her alopecia, however, has remained unchanged. One year after stopping treatment, her serum 25-hydroxycholecalciferol and parathormone levels were within normal limits but serum 1,25-dihydroxycholecalciferol was elevated.

Primary nephrotic syndrome in Arab children in Kuwait

Fifty-five Arab children with primary nephrotic syndrome (PNS) were seen at two regional hospitals in Kuwait over a 5-year period. There were 35 boys and 20 girls with a mean age of 5.3 years. The annual incidence was 7.2 and 6.0 per 100,000 children below 10 and 12 years of age, respectively. An initial response to steroids was noted in 84% with almost 50% responding within 1 week of therapy. Nine patients did not respond to steroids; histopathological classification of their renal biopsies showed 5 cases of membranoproliferative nephritis, 3 cases of focal segmental glomerulosclerosis and 1 case of membranous nephropathy. Microscopic haematuria was noted at presentation in 7 of 46 steroid responders, in all 5 patients with membranoproliferative disease and in 1 of 3 with focal segmental glomerulosclerosis. We conclude that the incidence of PNS seems to be higher among Arab children than in Western countries. With regard to initial biochemical abnormalities, steroid response and subsequent relapses, the pattern is the same as elsewhere.

Neurobrucellosis in children

Reports on nervous system involvement in brucellosis are rare in children. We report nine children with neurobrucellosis. The clinical presentation included meningitis in six patients, one with encephalitis, one with meningoencephalitis and one with meningomyeloencephalitis. The blood from all patients showed elevation in Brucella microagglutination test titers (greater than or equal to 1:640) and in Brucella-specific enzyme-linked immunosorbent assay for IgM (greater than or equal to 1:800), IgG (greater than or equal to 1:800) and IgA (greater than or equal to 1:800) antibodies. Brucella melitensis was recovered from the blood in five patients and from the cerebrospinal fluid in three patients. The cerebrospinal fluid showed lymphocytic pleocytosis in eight patients with elevated protein in three, decreased glucose in four and a Brucella microagglutination test titer of greater than or equal to 1:80 in all. Treatment with a combination of oral tetracyclines with intramuscular streptomycin was successful in five patients, rifampin with streptomycin in two, tetracycline with rifampin in one and tetracycline, rifampin and streptomycin in one. No relapses, mortality or sequelae occurred in our patients.

A Study of Early Neonatal Deaths at Kathmandu Medical College Teaching Hospital

Over 9 million deaths occur each year in the perinatal and neonatal periods globally. 98% of these deaths take place in the developing world. Nepal has a high neonatal mortality rate (NMR) of 38.6 per 1000 live births (2001). Two thirds of the newborn deaths usually occur in the first week of life (early neonatal death). Newborn survival has become an important issue to improve the overall health status and for achieving the millennium developmental goals of a developing country like Nepal. Aims and Objectives: This study was carried out to determine the causes of early neonatal deaths (ENND) at KMCTH in the two-year period from November 2003 to October2005 (Kartik 2060 B.S. to Ashoj 2062). Methodology: This is a prospective study of all the early neonatal deaths in KMCTH during the two-year study period. Details of each early neonatal death were filled in the standard perinatal death audit forms of the Department. Results: Out of the 1517 total births in the two-year period, there were 10 early neonatal deaths (ENND). Early neonatal death rate during the study period was 6.7 per 1000 live births and early neonatal death rate (excluding less than 1 kg) was 6.1 per 1000 live births The important causes of early neonatal deaths were extreme prematurity, birth asphyxia, congenital anomalies and septicaemia. During the study period, there was no survival of babies with a birth weight of less than 1 kg. Among the maternal characteristics, 80% of the mothers of early neonatal deaths were aged between 20-35 years. 50% of the mothers were primigravida. 50% of the mothers of ENNDs had delivered their babies by caesarean section.Discussion: Most of the early neonatal deaths were due to extreme prematurity. Birth asphyxia was the second most important cause of early neonatal deaths. 70% of ENNDs were among LBW babies. Prevention of premature delivery, proper management of very low birth weight babies and early detection and appropriate management of perinatal hypoxia have become important interventional strategies in reducing early neonatal deaths in KMCTH.Conclusion: Early neonatal mortality at KMCTH is fairly low. Good care during pregnancy, labour and after the birth of the baby has helped to achieve these results. Low cost locally made equipments were used to manage the sick newborns. Reduction of early neonatal deaths require more intensive care including use of ventilators, surfactant and parenteral nutrition and prevention of preterm births Key words: Early neonatal death (ENND), neonatal mortality   doi:10.3126/jnps.v27i2.1584 J. Nepal Paediatr. Soc. Vol 27(2), p.79-82

ANTHROPOMETRY AND BLOOD HAEMOGLOBIN STATUS OF WOMEN IN MAKWANPUR DISTRICT, NEPAL

BackgroundThe nutritional situation of women in Nepal remains precarious. Low energy, protein andmicronutrient intakes contribute to high levels of stunting and anaemia throughout thelife cycle. This suboptimal nutritional status contributes to high prevalences of low birthweight and death in early infancy. As background information for an ongoing study ofperinatal health interventions in 24 Village Development Committees (VDCs) of MakwanpurDistrict, a descriptive study of nutritional status and anaemia in a sample of women wascarried out.ObjectivesTo measure weight, height, mid-upper arm circumference (MUAC) and blood haemoglobinin non-pregnant married women of reproductive age.MethodsParticipants aged between 15 and 49 years were recruited at 12 sites in five VDCs. Personaldetails were collected in each case, after which height, weight, mid-upper arm circumference(MUAC) and blood haemoglobin level were measured.ResultsResults are available for 500 women. Mean height was 149.9 cm (95% confidence intervalfor mean 149.5 – 150.4 cm); mean weight was 45.5 kg (95% CI 44.9 - 46.1 kg); mean BodyMass Index (BMI) was 20.2 kg/m2(95% CI 20.0 – 20.4 kg/m2); mean MUAC was 23.47 cm(95% CI 23.2 – 23.7 cm). Overall, 27.8% (95% CI 24.1 – 32.2%) of women showed evidenceof Chronic Energy Deficiency (CED) on the basis of BMI, and 51.5% (95% CI 47.0 –56.0%) on the basis of MUAC. There were no significant differences in BMI or MUACbetween either ethnic or age groups. 35.3% of women were anaemic (95% CI 31.1 – 39.7%),one percent severely so. There were no significant differences in prevalence between ethnicgroups, but there was some evidence of an increase in anaemia prevalence with age.ConclusionsCED and anaemia appear common in Makwanpur District. As part of a package to improvenewborn infant outcome, access to and uptake of haematinics during pregnancy should bebeneficial. Community level intervention needs to attempt to address the issue of foodintake in young girls and women before improvements in nutritional status are possibleKey Words: Anaemia, anthropometry, nutritional status, Nepal.

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