Burden of tobacco-related cancers in urban, semi-urban and rural setting of Nepal: Findings from population-based cancer registries 2019.

BACKGROUND: Nepal is one of the high prevalent countries for tobacco use in Southeast Asia regions. Tobacco related cancer share the major burden since a decade, however, population-based estimates is still lacking. This study provides results from population-based cancer registries on tobacco-related cancer (TRCs) burden in Nepal. METHODS: The data were collected by population-based cancer registry conducted in nine districts by Nepal Health Research Council. The districts were categorized in urban, semi-urban and rural regions on the basis of geographical locations and facilities available in the regions. Analysis was done to identify tobacco-associated cancer incidence, mortality and patterns along with cumulative risk of having cancer before the age of 75 years. RESULTS: Tobacco-related cancer was 35.3% in men and 17.3% in women. We found that every one in 36 men and one in 65 women developed tobacco-related cancer before age 75 in Nepal. Cancer of lung, mouth, esophagus and larynx were among the five most common tobacco-related cancers in both men and women. The incidence of tobacco-associated cancers was higher in urban region with age adjusted rate 33.6 and 17.0 per 100,000 population for men and women respectively compared to semi-urban and rural regions. Tobacco-associated cancer mortality was significantly higher compared to incidence. CONCLUSION: The prevalence of tobacco-related cancer found high in Nepal despite of enforcement of tobacco control policy and strategies including WHO framework convention on tobacco control. Concerned authorities should focus towards monitoring of implemented tobacco control policy and strategies.

Erratum: Cervical Cancer Screening and HPV Vaccination in Nepal.

[This corrects the article DOI: 10.1055/s-0043-1764155.].

Assessment of the Knowledge of the Association between Periodontal Status and Pregnancy Outcome among Obstetricians and Gynecologists.

BACKGROUND: It has been more than two decades since a link was found between maternal oral health and adverse pregnancy outcome. Obstetricians and gynecologists play a core role in the screening, prevention and referral of the pregnant women for periodontal diseases. Thus, a study was conducted to assess the knowledge of the association between periodontal status and pregnancy outcomes. METHODS: An online survey was done by distributing self-administered questionnaire to the obstetricians and gynecologists. The survey consisted of three parts: demographic variables, consent and questionnaire. The qualitative data was recorded and analyzed. RESULTS: Out of 237 participants, 95.8% of the participants agreed that there is a relation between periodontal disease and pregnancy; 73.8% with preterm birth, 60.3% with low birth weight infants and 38.4% with pre-eclampsia. CONCLUSIONS: The knowledge of the association between periodontal status and pregnancy outcomes was found to be insufficient. The gynecologists must be provided with periodic orientation to enhance and update their knowledge on maternal periodontal health.

Vesico-Vaginal Fistula in Females in 2010-2020: a Systemic Review and Meta-analysis.

INTRODUCTION: In the Western world today, urogenital fistula, including vesicovaginal fistula (VVF), is rare. However, while it remains significant in developing parts of the world due to prolonged and obstructed labor, in this study, we systematically reviewed the existing literature, discussing VVF occurrence, its etiology, and outcomes. MATERIAL AND METHODS: We used electronic databases to search relevant articles from 2010-2020. The screening was performed with the help of Covidence. Relevant data from included studies were extracted in excel sheets, and final analysis was done using CMA-3 using proportion with 95% confidence interval (CI). RESULTS: Fifteen studies reported the VVF among the fistula series. The pooled result showed 76.57% cases of VVF (CI, 65.42-84.96), out of which 27.54% were trigonal, 55.70% supra-trigonal, and the rest with a varied description like circumferential, juxta-cervical, juxta-urethral. Obstetric etiology was commonly reported with 19.29% (CI, 13.26-27.21) with cesarean section and 31.14% (CI, 18.23-47.86) with obstructed labor. Hysterectomy was the commonly reported etiology among gynecological etiology (46.52%, CI; 36.17-57.19). Among different surgical treatments employed for fistula closure, 49.50% were by abdominal approach (CI, 37.23-61.82), and 42.31% by vaginal approach (CI, 31.82-53.54). Successful closure of fistula was reported in 87.09% of the surgeries (CI, 84.39-89.38). CONCLUSION: The vesicovaginal fistula is the most common type of genitourinary fistula. Major causes of fistula are gynecological surgery, obstructed labor, and cesarean section. The vaginal approach and abdominal are common modalities of repair of fistula with favorable outcomes in the majority of the patients.

Medical Research Education.

Research for clinical practice becomes robust if appropriate researchers are identified and trained. Utilization of research findings and its ownership can assure the appropriateness and real time research in society. Research on felt need would carry the better applicability than the observed need by external researcher. Thus the structured education program in medical research would be worth to start with. Keywords: Education program; medical research; research gap.

Prevalence, Risk Factors and Outcome of Pregnancy induced Hypertension in Nepal: A Meta-Analysis of Prevalence Studies.

BACKGROUND: Pregnancy induced hypertension is a major cause of global maternal mortality and morbidity. This review was conducted to fulfill the objective of evaluating the status of pregnancy induced hypertension in Nepal. METHODS: The protocol for this review was registered in PROSPERO (CRD42020211210). Pubmed, Embase, Google Scholar, Scopus and Pubmed Central were searched using appropriate keywords for relevant studies. Data analysis was performed using Comprehensive Meta-Analysis Software version 3. Forest plot was used to visualize the prevalence and risk factors of Pregnancy induced hypertension. Random effect model was used and the level of heterogeneity was high. Joanna Briggins Institute bias assessment tool was used for the analysis of bias in the included studies. RESULTS: Twenty studies were included in the review. The pooled prevalence of pre-eclampsia and eclampsia were 2.6% (95% CI, 1.2%-5.3%) and 0.5% (95% CI, 0.2%-1.1%) respectively. The majority of cases were young women and had not complete or unbooked antenatal visits. Cesarean delivery was the most common mode of deliveries in 50% of deliveries (proportion, 0.50; 95% CI, 0.40-0.60) among patients with PIH followed by vaginal deliveries in 43.1% (proportion, 0.431; 95% CI, 0.336-0.532); and rest 6.9% were vacuum/forceps assisted deliveries (proportion, 0.069; 95% CI, 0.050-0.093). Common maternal complications were abruption in 6.56% of Pregnancy induced hypertension cases, rest were pulmonary embolism, renal injury. CONCLUSIONS: The prevalence of pre-eclampsia and eclampsia in Nepal were 2.6% and 0.5%. Younger woman and women with poor antenatal checkups had increased risk of Pregnancy induced hypertension. Cesarean delivery was the most common route of delivery and common maternal complications were abruption placenta, pulmonary embolism, renal injury etc. Keywords: Eclampsia; hypertension; maternal mortality; Nepal; pre-eclampsia; pregnancy-induced.

Robsons Ten Group Classification of Cesarean Section at a Tertiary Center in Nepal.

BACKGROUND: Increasing trend in Ceasarean birth is the issue of both demand and supply side. One of the recommended tools to characterize every pregnancy admitted for childbirth is Robson ten-group classification system that may evaluate obstetric practice. The aim of the study was to assess the cesarean section pattern based on Robson's classification in a central referral hospital. METHODS: A retrospective census of childbirths at Paropakar Maternity and Women's Hospital in Kathmandu performed from September 2018 to February 2019 based on obstetric record. Robson ten-group classification system was the research tool to collect data and Robson Classification Report Table was used to evaluate the data. RESULTS: There were 10500 births with 34% (32-35%) overall cesarean section rate. Excluding spontaneous and induced labor the supposedly total prelabor CS is 14.5%. Group 1+2+3 size is 81% and 21% CS; 5+10 had 11.3% and 23.3% respectively. Prelabor CS (2b+4b) is 3.54% and additional 11% from malpresentation and preterm. Group CS rate from Class 5 onwards, and ratio of 1 and 2 are as recommended by Robson; 67% of CS were not picked up by Robson class due to indications evolved as the labor progresses and the attributes not pre-classified. CONCLUSIONS: The assessed quality of data and the type of obstetric population by Robson reference values prove this study as a representative research. But the indications of cesarean sections can be predicted for only one-third of pregnancy attributes classified by Robson class. To supplement this tool to reduce rising cesarean birth requires audit of indications at decision making level.

Thrombotic Pathology in Placenta of COVID Positive Pregnancy.

Covid positive pregnant women were increasingly getting delivery in the health institution. Most of them were asymptomatic and had positive report after their obstetric event was over because of emergency nature of care. Lack of autopsy is the lacunae in determining tissue pathology. One case of sudden intrauterine fetal death in Covid positive patient had induced delivery in the hospital and the placental histopathology examination showed widespread villous infarction, decidual arteriopathy with thrombosis and chorioamnionitis. Keywords: Covid positive; fetal death; placenta; thrombosis.

E-learning: a Modality of Medical Education in the Period of Crisis.

Delivery of medical education is challenged during the crisis like in pandemic. The purpose of this review is to explore the possible modality of medical education in pandemic condition. The modality depends on the availability of modality based resources, set curriculum and acceptance of modality. Blended learning and e-learning appear as the options of teaching-learning in crisis situation. Medical schools may adopt blended learning and e-learning modalities through curriculum that requires capacity building and availability of e-learning tools. Rescheduling the practical and clinical part in both training and evaluation are the immediate actions. Thus the existing method should be optimized by revision, replacement or postponement. Keywords: Crisis; curriculum; e-learning; medical education; pandemic.

Complete Recovery of Renal Function among Obstetric Patients with Acute Kidney Injury at a Tertiary Care Hospital: A Descriptive Cross-sectional Study.

INTRODUCTION: Acute kidney injury  is a rare complication of pregnancy and is associated with high maternal morbidity and mortality. Obstetric factors associated with it are preeclampsia/eclampsia, sepsis, hemorrhage and dehydration. Here, we aim to find out the prevalence of complete recovery of renal function among obstetric patients with acute kidney injury. METHODS: This is a descriptive cross-sectional study conducted in a tertiary care hospital from 1st July 2020 to 30th June 2021 where obstetric patients who had developed acute kidney injury were included and followed till 6 weeks of diagnosis. Ethical approval was obtained from Institutional Review Committee of Nobel Medical College and Teaching Hospital (IRC- NMCTH 437/2020). The convenience sampling method was used. Data entry and analysis were done using Statistical Package for Social Sciences version 21. Point estimate at 95% Confidence Interval was calculated along with frequency and proportion for binary data. RESULTS: Out of total 66 obstetric patients with acute kidney injury, 45 (68.2%) (57-79.3 at 95% Confidence Interval) had complete recovery of renal function. Rate of renal function recovery in Stage 1, Stage 2 and Stage 3 acute kidney injury were 19 (90%), 19 (86%) and 7 (58%) respectively. The most common causes of acute kidney injury were Preeclampsia/eclampsia 18 (40%), sepsis 23 (28.8%) and hemorrhage 10 (22.2%). CONCLUSIONS:  The prevalence of complete recovery in obstetric patients with acute kidney injury was similar to findings from other studies done in similar settings.

Perinatal Outcome of Second Twin in Third Trimester of Pregnancy.

BACKGROUND: With increasing trend of twin pregnancy and along with increasing advancement in neonatal care, survival rate of twin pregnancy has increased. However there is worse perinatal outcome in second twin in comparison with the first twin. METHODS: Hospital based observational cross-sectional study of 42 pregnant women with twin pregnancy at Paropakar Maternity and Women's Hospital was conducted from November 2019 to October 2020. The outcome of second twin was assessed in relation to gestational age, chorionicity, mode of delivery, delivery interval. McNemar test was used for analysis with 0.05 as the level of significance. RESULTS: Among 42 pair of twins, Apgar score of the second twin was found to be lower than the first twin (p=0.00) in general and in preterm gestation (p=0.115). Among twin who had monochorionic placenta; higher number of twin 1 had Apgar score of ?7(p=0.004). Among twin who had inter-delivery interval of <30min; higher number of twin1 had Apgar score of ?7 at 5 minutes. (p=0.00). CONCLUSIONS: Second twin has lower Apgar score in relationship to period of gestation, mode of delivery, inter-delivery interval, and chorionicity.

Diagnostic Accuracy of Risk of Malignancy Indices in Ovarian Tumor.

BACKGROUND: Screening test for ovarian cancer has not been developed yet but several tools exist to predict it. The aim is to find out the relative accuracy of commonly practiced versions of Risk of Malignancy Indices to predict ovarian malignancy pre-operatively. METHODS: Intention to treat cross sectional study at Paropakar Maternity and Women's Hospital in Kathmandu during last six months of year 2018. Cases with ovarian mass were taken pre-operatively with serum tumor markers, ultrasound and tumor Doppler study report. Pregnancy and diagnosed malignancy were excluded. Histopathology report traced post-operatively. All five versions of Risk of Malignancy Indices were analyzed by their predictive efficiency and different cut-off value of CA-125. RESULTS: 116 cases of ovarian tumor from 14 to 76 years (mean=35.2±11.7) were studied. There were 8.6% (n=10) malignant pathology; and isolated high vascular flow and solid component may predict malignancy (p=0.000). Up to 12 multiples of normal CA-125 value could not demonstrate clear predictive value for malignancy (p=0.061). By sensitivity, specificity, diagnostic accuracy and predictive values were similar for Risk of Malignancy Indices-1 and RMI-5 as well as Risk of Malignancy Indices-2 and Risk of Malignancy Indices-3. Cut-off of 250 is efficient by >90% and best at 300. Sensitivity of all Risk of Malignancy Indices versions were similar at cut-off level of 200, 250 and 300. CONCLUSIONS: Isolated value of CA-125 and size of tumor are not useful. All Risk of Malignancy Indices versions are reasonably good. Risk of Malignancy Indices value of 250 or more is the best predictive cut-off. Risk of Malignancy Indices-1 and Risk of Malignancy Indices-5 as well as Risk of Malignancy Indices-2 and Risk of Malignancy Indices-3 have similar predictive accuracy. Doppler study is not mandatory.

Prevalence and Mother-to-newborn Transmission of Hepatitis B Virus in Tertiary Care Hospital in Nepal.

BACKGROUND: The prevalence of hepatitis B infection is heterogeneous and ubiquitous. This study aimed to identify the prevalence of the infection among the pregnant women who attended in a tertiary care hospital, transmission of the infection in their newborn and associated risk factors. METHODS: A one year prospective study was conducted. Mother's venous blood was collected for the hepatitis B serological test during the antenatal care or before delivery; the newborn's cord blood was also collected for the HBsAg. RESULTS: A total 16400 pregnant women were tested; of them 53 were HBsAg positive. The total prevalence of the infection was 0.32% among the pregnant: 0.5% among the indigenous and 0.2% in other than indigenous. The infection was significantly high in the indigenous group compare to other than indigenous [2.596 (1.475-4.569), p=.001]. Thirty-two out of 53 hepatitis B positive pregnant were delivered in the hospital, of them 75% (n=24) were indigenous and 25% (n=8) were other than indigenous. Eight out of 32 were highly infectious (HBeAg+), of them majority (75%) were indigenous ethnicities. Twenty-one out of 32 were anti-HBe reactive, among which majority were indigenous ethnicities (76.2%). Six out of eight babies, born with HBeAg reactive mothers, were infected (75%), of which majority were indigenous ethnicities (67%). In total, one-fifth of the newborn delivered were HBsAg positive (18.8%). CONCLUSIONS: The prevalence of hepatitis B infection among the total pregnant was low. The proportion of the infection in the indigenous ethnicity was significantly high compared to other ethnic group, which shows that the infection was clustered among the indigenous people.

Incidence and Risk Factors of Pre-Eclampsia in the Paropakar Maternity and Women's Hospital, Nepal: A Retrospective Study.

This study aims to determine the incidence of pre-eclampsia and distribution of risk factors of pre-eclampsia at Paropakar Maternity and Women's Hospital, Kathmandu, Nepal. A retrospective study included 4820 pregnant women from 17 September to 18 December 2017. Data were obtained from the medical records of the hospital's Statistics Department. Associations between the risk factors and pre-eclampsia were determined using logistic regression analysis and expressed as odds ratios. The incidence rate of pre-eclampsia in the study population was 1.8%. Higher incidence of pre-eclampsia was observed for women older than 35 years (Adjusted Odds Ratio, AOR)= 3.27; (Confidence Interval, CI 1.42-7.52) in comparison to mothers aged 20-24 years, primiparous women (AOR = 2.12; CI 1.25-3.60), women with gestational age less than 37 weeks (AOR = 3.68; CI 2.23-6.09), twins pregnancy (AOR = 8.49; CI 2.92-24.72), chronic hypertension (AOR = 13.64; CI 4.45-41.81), urinary tract infection (AOR = 6.89; CI 1.28-36.95) and gestational diabetes (AOR = 11.79; CI 3.20-43.41). Iron and calcium supplementation appear to be protective. Age of the mothers, primiparity, early gestational age, twin pregnancy, chronic hypertension, urinary tract infection and gestational diabetes were the significant risk factors for pre-eclampsia. Iron and calcium supplementation and young aged women were somewhat protective.

Menopause Rating Scale: Validation and Applicability in Nepalese Women.

BACKGROUND: Menopausal Rating Scale is one of the globally used tools to assess quality of life in menopause and peri-menopause. The aim of this study is to validate the standard menopausal rating scale in Nepalese menopausal women and to test menopausal symptoms during clinical consultation at hospital. METHODS: Cross sectional validation study at Paropakar Maternity and Women's Hospital, Thapathali, Kathmandu. Five-step language translation of menopausal rating scale from English to Nepali, questionnaire clarity assessment with gynecologists and Likert scale questionnaire based interview to the clients. Reliability and validity tests applied. Each component of rating scale analyzed. RESULTS: Nepali version of menopausal rating scale developed. Acceptable level (Cronbach's Alpha = 0.77) of tools reliability obtained. Barlett's test of sphericity was highly significant and Pearson correlation between variables was significant. Average age of menarche was 15 years, and mean and modal value of menopause was 48 and 50 years respectively. First menopausal symptom was vasomotor flush in 62%, one-forth didn't experience flush, half experienced mild to moderate flush and rest one-fourth had severe to very severe form; 50% had significant sleep, bladder and sexual dysfunction. Three-fourth had vaginal dryness and musculoskeletal problem. One-half had some degree of mental dysfunction. CONCLUSIONS: Nepali version of menopausal rating scale developed. Baseline menopausal parameters obtained.

Improving the quality of maternity services in Nepal through accelerated implementation of essential interventions by healthcare professional associations.

OBJECTIVE: To assess whether the implementation of a package of activities through the joint action of three international healthcare professional associations (HCPAs) increased the use of essential interventions (EIs) for delivery and neonatal care. METHODS: A noncontrolled pre-intervention versus post-intervention study was conducted from June 13 to December 13, 2016, among women older than 18 years of age, who had delivered at one of two urban tertiary hospitals in Nepal. RESULTS: The study included 9252 women. Minimal change was found after the implementation of EIs that were used frequently at baseline (e.g. social support during delivery in the emergency room, and promotion and support for early initiation of breastfeeding). By contrast, an increase was recorded for some EIs that had not been used regularly at baseline. For example, the rate of timely administration of prophylactic antibiotics before cesarean delivery increased from 0.0% (0/496) to 94.0% (409/435) at one hospital. Nonetheless, some EIs with low use at baseline did not show improvement after implementation (e.g. kangaroo mother care). CONCLUSION: The present study strengthened previous findings regarding the uptake of EIs following joint promotion by HCPAs in low-income settings.

Incidence of intrapartum stillbirth and associated risk factors in tertiary care setting of Nepal: a case-control study.

BACKGROUND: Each year, 1.2 million intrapartum stillbirths occur globally. In Nepal, about 50 % of the total number of stillbirths occur during the intrapartum period. An understanding of the risk factors associated with intrapartum stillbirth will facilitate the development of preventative strategies to reduce the associated burden of death. This study was conducted in a tertiary-care setting with the aim to identify risk factors associated with intrapartum stillbirth. METHODS: A case-control study was completed from July 2012 to September 2013. All women who had an intrapartum stillbirth during the study period were included as cases, and 20 % of women with live births were randomly selected upon admission to create the referent population. Relevant information was retrieved from clinical records for case and referent women. In addition, interviews were completed with each woman to determine their demographic and obstetric history. RESULTS: During the study period, 4,476 women were enrolled as referents and 136 women had intrapartum stillbirths. The following factors were found to be associated with an increased risk for intrapartum stillbirth: poor familial wealth quintile (Adj OR 1.8, 95 % CI-1.1-3.4); less maternal education (Adj OR, 3.2 95 % CI-1.8-5.5); lack of antenatal care (Adj OR, 4.8 95 % CI 3.2-7.2); antepartum hemorrhage (Adj OR 2.1, 95 % CI 1.1-4.2); multiple births (Adj. OR-3.0, 95 % CI- 1.9-5.4); obstetric complication during labor (Adj. OR 4.5, 95 % CI-2.9-6.9); lack of fetal heart rate monitoring per protocol (Adj. OR-1.9, 95 % CI 1.5-2.4); lack of partogram use (Adj. OR-2.1, 95 % CI 1.1-4.1); small-for-gestational age (Adj. OR-1.8, 95 % CI-1.2-1.7); preterm birth (Adj. OR-5.4, 95 % CI 3.5-8.2); and being born preterm with a small-for-gestational age (Adj. OR-9.0, 95 % CI 7.3-15.5). CONCLUSION: Being born preterm with a small-for-gestational age was associated with the highest risk for intrapartum stillbirth. Inadequate fetal heart rate monitoring and partogram use are preventable risk factors associated with intrapartum stillbirth; by increasing adherence to these interventions the risk of intrapartum stillbirth can be reduced. The association of the lack of appropriate antenatal care with intrapartum stillbirth indicates that quality antenatal care may improve fetal health and outcomes. TRIAL REGISTRATION: ISRCTN97846009.

Maternal near-miss: a multicenter surveillance in Kathmandu Valley.

INTRODUCTION: Multicenter surveillance has been carried out on maternal near-miss in the hospitals with sentinel units. Near-miss is recognized as the predictor of level of care and maternal death. Reducing Maternal Mortality Ratio is one of the challenges to achieve Millennium Development Goal. The objective was to determine the frequency and the nature of near-miss events and to analyze the near-miss morbidities among pregnant women. METHODS: A prospective surveillance was done for a year in 2012 at nine hospitals in Kathmandu valley. Cases eligible by definition were recorded as a census based on WHO near-miss guideline. Similar questionnaires and dummy tables were used to present the results by non-inferential statistics. RESULTS: Out of 157 cases identified with near-miss rate of 3.8 per 1000 live births, severe complications were postpartum hemorrhage 62 (40%) and preeclampsia-eclampsia 25 (17%). Blood transfusion 102 (65%), ICU admission 85 (54%) and surgery 53 (32%) were common critical interventions. Oxytocin was main uterotonic used both prophylactically and therapeutically at health facilities. Total of 30 (19%) cases arrived at health facility after delivery or abortion. MgSO4 was used in all cases of eclampsia. All laparotomies were performed within three hours of arrival. Near-miss to maternal death ratio was 6:1 and MMR was 62. CONCLUSIONS: Study result yielded similar pattern amongst developing countries and same near-miss conditions as the causes of maternal death reported by national statistics. Process indicators qualified the recommended standard of care. The near-miss event could be used as a surrogate marker of maternal death and a window for system level intervention.

In the Nepalese context, can a husband's attendance during childbirth help his wife feel more in control of labour?

BACKGROUND: A husband's support during childbirth is vital to a parturient woman's emotional well-being. Evidence suggests that this type of support enables a woman to feel more in control during labour by reducing maternal anxiety during childbirth. However, in Nepal, where childbearing is considered an essential element of a marital relationship, the husband's role in this process has not been explored. Therefore, we examined whether a woman in Nepal feels more in control during labour when her husband is present, compared to when another woman accompanies her or when she has no support person. METHODS: The study participants were low risk primigravida women in the following categories: women who gave birth with their husband present (n = 97), with a female friend present (n = 96), with mixed support (n = 11), and finally, a control group (n = 105). The study was conducted in the public maternity hospital in Kathmandu in 2011. The Labour Agentry Scale (LAS) was used to measure the extent to which women felt in control during labour. The study outcome was compared using an F-test from a one-way analysis of variance, and multiple regression analyses. RESULTS: The women who gave birth with their husband's support reported higher mean LAS scores (47.92 ± 6.95) than the women who gave birth with a female friend's support (39.91 ± 8.27) and the women in the control group (36.68 ± 8.31). The extent to which the women felt in control during labour was found to be positively associated with having their husband's company during childbirth (ß = 0.54; p < 0.001) even after adjusting for background variables. In addition, having a female friend's company during childbirth was related to the women's feeling of being in control during labour (ß = 0.19; p < 0.001) but the effect size was smaller than for a husband's company. CONCLUSION: The results show that when a woman's husband is present at the birth, she feels more in control during labour. This finding has strong implications for maternity practices in Nepal, where maternity wards rarely encourage a woman to bring her husband to a pregnancy appointment and to be present during childbirth.