Burden, prevention and control of tobacco consumption in Nepal: a narrative review of existing evidence.

Tobacco consumption is one of the major public health problems in the world. Annually, 27 100 premature deaths are attributed to tobacco-related diseases in Nepal. Despite enacting different policies and strategies, the prevalence of tobacco consumption is still high. This study aims to synthesize prevalence, factors associated with its consumption and the policy initiatives for prevention and control in Nepal. This review includes peer-reviewed studies retrieved from two databases (PubMed and EMBASE) and published from 2000 to 2018, and policy initiatives on tobacco prevention and regulations in Nepal. A total of 32 studies and 5 policy documents were reviewed. Findings suggest that tobacco consumption was higher among men, illiterates, older people, people living in rural and mountainous areas and those who initiated smoking as adolescents. Peer pressure and parental/family smoking were major contributing factors for tobacco initiation. Policy analysis showed that low excise tax, weak monitoring mechanisms, poor compliance to bans on the advertisement and promotion of tobacco, smoke-free zones and insufficient programs on tobacco cessation were the major factors behind weak implementation of tobacco-control policies. Hence, targeted and high-risk group tobacco-cessation interventions, increasing taxation and strict policy implementation are crucial for effective tobacco prevention and control in Nepal.

Association between Intimate Partner Violence and Abortion in Nepal: A Pooled Analysis of Nepal Demographic and Health Surveys (2011 and 2016).

BACKGROUND: Intimate partner violence (IPV) adversely affects female reproductive health in different ways. However, the relationship between IPV and abortion has not been adequately examined in Nepal. This study is aimed at examining the association between IPV and abortion in Nepal. METHODS: Data for this study was derived from the Nepal Demographic Health Surveys (NDHS) of 2011 and 2016. A total of 8641 women aged 15-49 years were selected for the violence module in NDHS 2011 and 2016. The analysis was restricted to 2978 women who reported at least one pregnancy five years preceding each survey. Among them, 839 women who experienced different forms of violence were included in the analysis. Various forms of IPV were taken as exposure variables while abortion as an outcome of interest. The study employed logistic regression analysis to examine the association between IPV and abortion. RESULTS: Nearly one in three (28.2%) women experienced any forms of IPV. A total of 22.2% women experienced physical violence. Almost one in five (19.5%) women were slapped. More than half (52.8%) of the women with no education experienced IPV. The logistic regression analyses showed a significant association between IPV and abortion. Women with severe physical violence had nearly two-fold higher odds (adjusted Odds Ratio (aOR) = 1.68; 95% CI: 1.06, 2.64) of having abortion. Similarly, women who reported physical violence were more likely to have abortion (aOR = 1.54; 95% CI: 1.09, 2.19) compared to those who did not experience such violence. CONCLUSION: Intimate partner violence is associated with abortion in Nepal. It is imperative that effective implementation of IPV-preventive measures through the promotion of appropriate social and policy actions can help reduce abortion in Nepal.

Factors associated with unsafe abortion practices in Nepal: Pooled analysis of the 2011 and 2016 Nepal Demographic and Health Surveys.

BACKGROUND: Unsafe abortion contributes to maternal morbidities, mortalities as well as social and financial costs to women, families, and the health system. This study aimed to examine the factors associated with unsafe abortion practices in Nepal. METHODS: Data were derived from the 2011 and 2016 Nepal Demographic and Health Surveys (NDHS). A total of 911 women aged 15-49 years who aborted five years prior to surveys were included in the analysis. The multivariate logistic regression analysis was employed to determine factors associated with unsafe abortion. RESULTS: Unsafe abortion rate was seven per 1000 women aged 15-49 years. This research found that women living in the Mountains (adjusted Odds Ratio (aOR) 2.36; 95% CI 1.21, 4.60), or those who were urban residents (aOR 2.11; 95% CI 1.37, 3.24) were more likely to have unsafe abortion. The odds of unsafe abortion were higher amongst women of poor households (aOR 2.16; 95% CI 1.18, 3.94); Dalit women (aOR 1.89; 95% CI 1.02, 3.52), husband with no education background (aOR 2.12; 95%CI 1.06, 4.22), or women who reported agriculture occupation (aOR 1.82; 95% CI 1.16, 2.86) compared to their reference's group. Regardless of knowledge on legal conditions of abortion, the probability of having unsafe abortion was significantly higher (aOR 5.13; 95% CI 2.64, 9.98) amongst women who did not know the location of safe abortion sites. Finally, women who wanted to delay or space childbirth (aOR 2.71; 95% CI 1.39, 5.28) or those who reported unwanted birth (aOR = 2.33; 95% CI 1.19, 4.56) were at higher risk of unsafe abortion. CONCLUSION: Going forward, increasing the availability of safe abortion facilities and strengthening family planning services can help reduce unsafe abortion in Nepal. These programmatic efforts should be targeted to women of poor households, disadvantaged ethnicities, and those who reside in mountainous region.

Social determinants of health affecting utilisation of routine maternity services in Nepal: a narrative review of the evidence.

Nepal has one of the highest maternal and neonatal mortality rates among low- and middle-income countries. Nepal's health system focuses on life-saving interventions provided during the antenatal to postpartum period. However, the inequality in the uptake of maternity services is of major concern. This study aimed to synthesise evidence from the literature regarding the social determinants of health on the use of maternity services in Nepal. We conducted a structured narrative review of studies published from 1994 to 2016. We searched five databases: PubMed; CINAHL; EMBASE; ProQuest and Global Index Medicus using search terms covering four domains: access and use; equity determinants; routine maternity services and Nepal. The findings of the studies were summarised using the World Health Organization's Social Determinants of Health framework. A total of 59 studies were reviewed. A range of socio-structural and intermediary-level determinants was identified, either as facilitating factors, or as barriers, to the uptake of maternity services. These determinants were higher socioeconomic status; education; privileged ethnicities such as Brahmins/Chhetris, people following the Hindu religion; accessible geography; access to transportation; family support; women's autonomy and empowerment; and a birth preparedness plan. Findings indicate the need for health and non-health sector interventions, including education linked to job opportunities; mainstreaming of marginalised communities in economic activities and provision of skilled providers, equipment and medicines. Interventions to improve maternal health should be viewed using a broad 'social determinants of health' framework.

Trends and factors associated with pregnancies among adolescent women in Nepal: Pooled analysis of Nepal Demographic and Health Surveys (2006, 2011 and 2016).

INTRODUCTION: Adolescent pregnancy is a significant cost to mother, newborn, and their family and society. Despite the enormous health and social impact of adolescent pregnancy, there is a dearth of nationally representative studies on factors associated with adolescent pregnancies in Nepal. Therefore, this study aimed to examine trends and factors associated with adolescent pregnancies in Nepal, using pooled data of three nationally representative demographic surveys. METHODS: Data for this study was derived from the recent three consecutive (2006, 2011 and 2016) Nepal Demographic and Health Surveys (NDHS). A total of 7,788 adolescent women aged 15-19 years included in the analysis. Trends and multivariable logistic regression analysis was performed to examine the factors associated with adolescent pregnancy. RESULTS: Over the study period (2006-2016), the rate of adolescent pregnancy was 173 [95% Confidence Interval (CI): 159, 188] per 1000 women aged 15-19 years. Adolescent pregnancy was significantly higher among woman with middle household wealth index [adjusted Odds Ratio (aOR) 2.19, 95% confidence interval CI 1.65, 2.91] or poor household wealth index (aOR 2.37, 95% CI 1.76, 3.21). Similarly, Dalit (aOR 1.87, 95% CI 1.50, 2.34) or Madhesi (aOR 1.67, 95% CI 1.32, 2.11); and unemployed (aOR 1.28, 95% CI 1.09, 1.50) women had higher odds of adolescent pregnancies. In contrast, adolescent pregnancy was significantly lower among educated women (aOR 0.60, 95% CI 0.48, 0.74), and women with access to media exposure to public health issues (aOR 0.75, 95% CI 0.64, 0.88). CONCLUSIONS: Access to the media exposure on public health issues can be the effective efforts to reduce adolescent pregnancy. Women who have low maternal education, low wealth index, unemployed, and ethnic groups such as Dalits, and Madeshi needs to be targeted while designing and implementing policies and programs.

Female Community Health Volunteers in Community-Based Health Programs of Nepal: Future Perspective.

Nepal's Female Community Health Volunteers (FCHVs) program started in 1988. In the early years of program initiation, FCHVs were assigned to promote and distribute the family planning commodities such as condoms and pills. Over past three decades, FCHVs' roles have gradually expanded beyond family planning program and especially are focused on maternal and child health services at a large scale. FCHVs are an integral part of many community-based health programs, and their roles are instrumental in linking families and communities to community health workers and periphery-level health facilities. However, the fragmented nature of health programs poses a challenge for these health volunteers to coordinate activities and deliver the results. This perspective aims to review their contribution, challenges and recommend an integrated FCHV program model to support in the implementation of the community-based health interventions effectively.

Barriers to utilization of childbirth services of a rural birthing center in Nepal: A qualitative study.

BACKGROUND: Maternal mortality and morbidity are public health problems in Nepal. In rural communities, many women give birth at home without the support of a skilled birth attendant, despite the existence of rural birthing centers. The aim of this study was to explore the barriers and provide pragmatic recommendations for better service delivery and use of rural birthing centers. METHODS: We conducted 26 in-depth interviews with service users and providers, and three focus group discussions with community key informants in a rural community of Rukum district. We used the Adithya Cattamanchi logic model as a guiding framework for data analysis. RESULTS: Irregular and poor quality services, inadequate human and capital resources, and poor governance were health system challenges which prevented service delivery. Contextual barriers including difficult geography, poor birth preparedness practices, harmful culture practices and traditions and low level of trust were also found to contribute to underutilization of the birthing center. CONCLUSION: The rural birthing center was not providing quality services when women were in need, which meant women did not use the available services properly because of systematic and contextual barriers. Approaches such as awareness-raising activities, local resource mobilization, ensuring access to skilled providers and equipment and other long-term infrastructure development works could improve the quality and utilization of childbirth services in the rural birthing center. This has resonance for other centers in Nepal and similar countries.

Factors Associated with Underweight among Under-Five Children in Eastern Nepal: Community-Based Cross-sectional Study.

BACKGROUND: Undernutrition is a leading cause of morbidity and mortality in children in developing countries including Nepal. This study aimed to identify sociodemographic, environmental, and maternal and child health (MCH) factors associated with objectively assessed underweight among children aged under 5 years in Ilam district of eastern Nepal. METHODS: A community-based cross-sectional study of 300 mothers of children under 5 years was conducted using interviewer-administered questionnaires from July to August 2012. The sample was derived by randomly selecting three village development committees (VDCs), then three wards from each of these three VDCs were selected making a total sample of nine wards. Finally, individuals were selected from the nine wards using systematic random sampling. Chi-square tests were used to identify factors associated with childhood underweight. Logistic regression analyses were conducted to determine odds ratios for the factors associated with underweight. RESULTS: The prevalence of underweight was 37% [95% confidence interval (CI): 33-43%]. Children who were more than 24 months of age were more likely to be underweight (adjusted odds ratio (aOR) = 2.72; 95% CI: 1.57, 4.70) than children aged less than 24 months. Children of families who consumed water without treatment had higher odds of being underweight (aOR = 2.48; 95% CI: 1.28, 4.78) than those who used water after boiling. Children whose mother perceived their size at birth as normal were more likely to be normal weight (aOR = 0.40; 95% CI: 0.16, 0.99) compared to a smaller size at birth. Children whose growth was monitored had a low chance of being underweight (aOR = 0.35, 95% CI: 0.15, 0.97). CONCLUSION: Nearly two-fifth of under-five children were found to be underweight. The age of children, drinking water purification practices, growth monitoring, and mother's perception of size at birth were significantly associated with childhood underweight. These findings suggest that interventions focusing on access to child growth monitoring, and water and sanitation practices may reduce the childhood underweight.

Determinants of infant and young child feeding practices in Rupandehi, Nepal.

BACKGROUND: Undernutrition is a major problem in Nepal and meeting the minimum dietary standard is essential for growth and development of young children. Continuous monitoring of such practices is important to inform policy and program formulation. This study aimed to assess complementary feeding practices, and associated factors in Western Nepal. METHODS: This was a cross-sectional study conducted in Rupandehi district of Western Nepal. Face-to-face interviews were conducted among 178 mothers of young children aged 6-23 months using a structured questionnaire and data on complementary feeding practices. These practices were reported as frequency distribution and the factors associated were ascertained using multiple logistic regression. RESULTS: Only 57% of mothers initiated complementary feeding at the age of 6 months. While the proportion of young children receiving minimum meal frequency was reasonably high (84 %), meal diversity (35%) and minimum acceptable diet (33%) remained low. Maternal education and having had their children's growth monitored were independently associated with receiving minimum acceptable diet. CONCLUSION: Few infants and young children received the recommended infant and young children feeding practices. Implementing health promotion programs that educate and enhance the skills of mothers should be a priority for future nutrition interventions.

Newborn Health Interventions and Challenges for Implementation in Nepal.

Neonatal mortality is a major challenge in reducing child mortality rates in Nepal. Despite efforts by the Government of Nepal, data from the last three demographic and health surveys show a rise in the contribution of neonatal deaths to infant and child mortality. The Government of Nepal has implemented community-based programs that were piloted and then scaled up based on lessons learned. These programs include, but are not limited to ensuring safe motherhood, birth preparedness package, community-based newborn care package, and integrated management of childhood illnesses. Despite the implementation of such programs on a larger scale, their effective coverage is yet to be achieved. Health system challenges included an inadequate policy environment, funding gaps, inadequate procurement, and insufficient supplies of commodities, while human resource management has been found to be impeding service delivery. Such bottlenecks at policy, institutional and service delivery level need to be addressed incorporating health information in decision-making as well as working in partnership with communities to facilitate the utilization of available services.

Barriers to Utilization of Antenatal Care Services in Eastern Nepal.

BACKGROUND: World Health Organization recommends at least four pregnancy check-ups for normal pregnancies. Ministry of Health and Population Nepal has introduced various strategies to promote prenatal care and institutional delivery to reduce maternal and child deaths. However, maternal health service utilization is low in some selected socio-economic and ethnic groups. Hence, this study aims to assess barriers to the recommended four antenatal care (4ANC) visits in eastern Nepal. METHODS: A cross-sectional quantitative study was conducted in Sunsari district. A total of 372 randomly selected women who delivered in the last year preceding the survey were interviewed using a semi-structured questionnaire. Bivariate and multivariate logistic regression analysis was carried out to identify barriers associated with 4ANC visits. RESULTS: More than two-third women (69%) attended at least 4ANC visits. The study revealed that women exposed to media had higher chance of receiving four or more ANC visits with an adjusted odds ratio (aOR = 3.5, 95% CI: 1.2-10.1) in comparison to women who did not. Women from an advantaged ethnic group had more chance of having 4ANC visits than respondents from a disadvantaged ethnic group (aOR = 2.4, 95% CI: 2.1-6.9). Similarly, women having a higher level of autonomy were nearly three times more likely (aOR = 2.9, 95% CI: 1.5-5.6) and richer women were twice (aOR = 2.3, 95% CI: 1.1-5.3) as likely to have at least 4ANC visits compared to women who had a lower level of autonomy and were economically poor. CONCLUSION: Being from disadvantaged ethnicity, lower women's autonomy, poor knowledge of maternal health service and incentive upon completion of ANC, less media exposure related to maternal health service, and lower wealth rank were significantly associated with fewer than the recommended 4ANC visits. Thus, maternal health programs need to address such socio-cultural barriers for effective health care utilization.

Prevalence and factors associated with depressive symptoms among post-partum mothers in Nepal.

BACKGROUND: Post-partum depression is a common complication of women after childbirth. The objective of this study was to determine the prevalence of and factors associated with depressive symptoms among post-partum mothers attending a child immunization clinic at a maternity hospital in Kathmandu, Nepal. METHODS: This cross-sectional study was conducted among 346 post-partum mothers at six to ten weeks after delivery using systematic random sampling. Mothers were interviewed using a semi-structured questionnaire. The Edinburgh Postnatal Depression Scale (EPDS) was used to screen for depressive symptoms. Logistic regression analysis was used to calculate the association of post-partum depressive symptoms with socio-demographic and maternal factors. RESULTS: The prevalence of post-partum depressive symptoms among mothers was 30%. Mothers aged 20 to 29 years were less likely to have depressive symptoms (adjusted odds ratio (aOR) = 0.40; 95% CI: 0.21-0.76) compared to older mothers. Similarly, mothers with a history of pregnancy-induced health problems were more likely to have depressive symptoms (aOR = 2.16; CI: 1.00-4.66) and subjective feelings of stress (aOR = 3.86; CI: 1.84-4.66) than mothers who did not. CONCLUSIONS: The number of post-partum mothers experiencing depressive symptoms was high; almost one-third of the participants reported having them. Pregnancy-induced health problems and subjective feelings of stress during pregnancy in the post-partum period were found to be associated with depressive symptoms among these women. Screening of depressive symptoms should be included in routine antenatal and postnatal care services for early identification and prevention.