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.

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.

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.

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.

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.

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.