Maternal mental health and economic autonomy in lowland rural Nepal: Do parents-in-law provide constraint or support?

Background and objectives: In patrilocal societies, married women typically co-reside with their parents-in-law, who may act in their son's reproductive interests. These relationships may shape maternal mental health and autonomy. Few studies have examined these dynamics from an evolutionary perspective. Theoretically, marital kin may increase their fitness by increasing maternal investment or by reducing paternity uncertainty. We explored how co-residence with parents-in-law and husband is associated with maternal outcomes to evaluate whether marital kin provide support or constraint. Methodology: We analysed data from 444 households in rural lowland Nepal. Maternal mental health was assessed by General Health Questionnaire. Logistic regression models investigated whether, relative to mothers living with both husband and parents-in-law, those co-resident with other combinations of relatives had poorer mental health and lower household economic autonomy (decision-making, bargaining power), adjusting for socio-economic confounders. Results: Co-residence with husband only, or neither husband nor parents-in-law, was associated with higher odds of mothers reporting feeling worthless and losing sleep but also earning income and making household expenditure decisions. Husband co-residence was associated with overall maternal distress but also with less unpaid care work and greater decision-making responsibility. There were no differences in maternal outcomes for mothers living with parents-in-law only, relative to those living with both husbands and parents-in-law. Conclusions and implications: Co-residence of parents-in-law and husbands was associated with contrasting patterns of maternal mental health and economic autonomy. We suggest that different marital kin place different economic demands on mothers, while restricting their autonomy in different ways as forms of 'mate-guarding'.

The role of education in child and adolescent marriage in rural lowland Nepal.

Marriage during childhood and adolescence adversely affects maternal and child health and well-being, making it a critical global health issue. Analysis of factors associated with women marrying ≥18 years has limited utility in societies where the norm is to marry substantially earlier. This paper investigated how much education Nepali women needed to delay marriage across the range of ages from 15 to ≥18 years. Data on 6,406 women aged 23-30 years were analysed from the Low Birth Weight South Asia Trial on the early-marrying and low-educated Maithili-speaking Madhesi population in Terai, Nepal. Multivariable logistic regression models assessed the associations of women's education with marrying aged ≥15, ≥16, ≥17 and ≥18 years. Cox proportional hazards regression models quantified the hazard of marrying. Models adjusted for caste affiliation. Women married at median age of 15 years and three-quarters were uneducated. Women's primary and lower-secondary education were weakly associated with delaying marriage, whether the cut-off to define early marriage was 15, 16, 17 or 18 years, with stronger associations for secondary education. Caste associations were weak. Overall, models explained relatively little of the variance in the likelihood of marriage at different ages. The joint effects of lower-secondary and higher caste affiliation and of secondary/higher education and mid and higher caste affiliation reduced the hazard of marrying. In early-marrying and low-educated societies, changing caste-based norms are unlikely to delay women's marriage. Research on broader risk factors and norms that are more relevant for delaying marriage in these contexts is needed. Gradual increases in women's median marriage age and increased secondary education may, over time, reduce child and adolescent marriage.

Antenatal care in Nepal: a qualitative study into missed opportunities in the first trimester.

BACKGROUND: Use of timely antenatal care has been identified as key to facilitating healthy pregnancies worldwide. Although considerable investment has been made to enhance maternal health services in Nepal, approximately one-third of women do not attend antenatal care until after the first trimester (late). These women miss out on the benefits of screening and interventions that are most effective in the first trimester. OBJECTIVE: This study aimed to identify the missed opportunities of women who do not attend antenatal care in the first trimester, and to explore some of the factors underlying late attendance and consider potential solutions for minimizing these missed opportunities in the future. STUDY DESIGN: This study was conducted in 3 hospitals in Nepal. Focus groups (n=18) with a total of 48 postnatal women and 49 staff members, and 10 individual interviews with stakeholders were conducted. Purposive sampling facilitated the obtainment of a full range of maternity experiences, staff categories, and stakeholder positions. Data were qualitative and analyzed using a thematic approach. RESULTS: Limited awareness among women of the importance of early antenatal care was reported as a key factor behind attendance only after the first trimester. The family and community were described as significant influencers in women's decision-making regarding the timing of antenatal care. The benefits of early ultrasound scanning and effective supplementation in pregnancy were the major missed opportunities. Increasing awareness, reducing cost, and enhancing interprofessional collaboration were suggested as potential methods for improving timely initiation of antenatal care. CONCLUSION: Limited awareness continues to drive late attendance to antenatal care after the first trimester. Investment in services in the first trimester and community health education campaigns are needed to improve this issue and enhance maternal and neonatal outcomes.

Feeding, caregiving practices, and developmental delay among children under five in lowland Nepal: a community-based cross-sectional survey.

BACKGROUND: Nurturing care, including adequate nutrition, responsive caregiving and early learning, is critical to early childhood development. In Nepal, national surveys highlight inequity in feeding and caregiving practices for young children. Our objective was to describe infant and young child feeding (IYCF) and cognitive and socio-emotional caregiving practices among caregivers of children under five in Dhanusha district, Nepal, and to explore socio-demographic and economic factors associated with these practices. METHODS: We did a cross-sectional analysis of a subset of data from the MIRA Dhanusha cluster randomised controlled trial, including mother-child dyads (N = 1360), sampled when children were median age 46 days and a follow-up survey of the same mother-child dyads (N = 1352) when children were median age 38 months. We used World Health Organization IYCF indicators and questions from the Multiple Indicator Cluster Survey-4 tool to obtain information on IYCF and cognitive and socio-emotional caregiving practices. Using multivariable logistic regression models, potential explanatory household, parental and child-level variables were tested to determine their independent associations with IYCF and caregiving indicators. RESULTS: The prevalence of feeding indicators varied. IYCF indicators, including ever breastfed (99%), exclusive breastfeeding (24-hour recall) (89%), and vegetable/fruit consumption (69%) were common. Problem areas were early initiation of breastfeeding (16%), colostrum feeding (67%), no pre-lacteal feeding (53%), timely introduction of complementary feeding (56%), minimum dietary diversity (49%) and animal-source food consumption (23%). Amongst caregiving indicators, access to 3+ children's books (7%), early stimulation and responsive caregiving (11%), and participation in early childhood education (27%) were of particular concern, while 64% had access to 2+ toys and 71% received adequate care. According to the Early Child Development Index score, only 38% of children were developmentally on track. Younger children from poor households, whose mothers were young, had not received antenatal visits and delivered at home were at higher risk of poor IYCF and caregiving practices. CONCLUSIONS: Suboptimal caregiving practices, inappropriate early breastfeeding practices, delayed introduction of complementary foods, inadequate dietary diversity and low animal-source food consumption are challenges in lowland Nepal. We call for urgent integrated nutrition and caregiving interventions, especially as interventions for child development are lacking in Nepal.

Girls start life on an uneven playing field: Evidence from lowland rural Nepal.

Background and objectives: Evolutionary research on the sex ratio at birth (SRB) has focused on explaining variability within and between populations, and whether parental fitness is maximized by producing daughters or sons. We tested predictors of SRB in a low-income setting, to understand whether girls differ from boys in their likelihood of being born into families with the capacity to invest in them, which has implications for their future health and fitness. Methodology: We used data from a cluster randomized control trial from lowland rural Nepal (16 115 mother-child dyads). We applied principal component analysis to extract two composite indices reflecting maternal socio-economic and reproductive (parity, age) capital. We fitted mixed-effects logistic regression models to estimate odds ratios of having a girl in association with these individual factors and indices. Results: The SRB was 112. Compared to the global reference SRB (105), there were seven missing girls per 100 boys. Uneducated, early-marrying, poorer and shorter mothers were more likely to give birth to girls. Analysing composite maternal indices, lower socio-economic and reproductive capital were independently associated with a greater likelihood of having a girl. Conclusions and implications: In this population, girls start life facing composite disadvantages, being more likely than boys to be born to mothers with lower socio-economic status and reproductive capital. Both physiological and behavioural mechanisms may contribute to these epidemiological associations. Differential early exposure by sex to maternal factors may underpin intergenerational cycles of gender inequality, mediated by developmental trajectory, education and socio-economic status.

Associations of age at marriage and first pregnancy with maternal nutritional status in Nepal.

Background and objectives: Women's nutritional status is important for their health and reproductive fitness. In a population where early marriage is common, we investigated how women's nutritional status is associated with their age at marriage (marking a geographical transfer between households), and at first pregnancy. Methodology: We used data from a cluster-randomized control trial from lowland Nepal (n = 4071). Outcomes including body mass index (BMI) were measured in early pregnancy and trial endpoint, after delivery. We fitted mixed-effects linear and logistic regression models to estimate associations of age at marriage and age at pregnancy with outcomes, and with odds of chronic energy deficiency (CED, BMI <18.5 kg/m2), at both timepoints. Results: BMI in early pregnancy averaged 20.9 kg/m2, with CED prevalence of 12.5%. In 750 women measured twice, BMI declined 1.2 (95% confidence interval 1.1, 1.3) kg/m2 between early pregnancy and endpoint, when CED prevalence was 35.5%. Early pregnancy was associated in dose-response manner with poorer nutritional status. Early marriage was independently associated with poorer nutritional status among those pregnant ≤15 years, but with better nutritional status among those pregnant ≥19 years. Conclusions and implications: The primary determinant of nutritional status was age at pregnancy, but this association also varied by marriage age. Our results suggest that natal households may marry their daughters earlier if food insecure, but that their nutritional status can improve in the marital household if pregnancy is delayed. Marriage age therefore determines which household funds adolescent weight gain, with implications for Darwinian fitness of the members of both households.

A systematic review and narrative synthesis of antenatal interventions to improve maternal and neonatal health in Nepal.

BACKGROUND: Maternal and neonatal mortality rates remain high in many economically underdeveloped countries, including Nepal, and good quality antenatal care can reduce adverse pregnancy outcomes. However, identifying how to best improve antenatal care can be challenging. OBJECTIVE: To identify the interventions that have been investigated in the antenatal period in Nepal for maternal or neonatal benefit. We wanted to understand their scale, location, cost, and effectiveness. STUDY DESIGN: Online bibliographic databases (Cochrane Central, MEDLINE, Embase, CINAHL Plus, British Nursing Index, PsycInfo, Allied and Complementary Medicine) and trial registries (ClinicalTrials.gov and the World Health Organization Clinical Trials Registry Platform) were searched from their inception till May 24, 2020. We included all studies reporting any maternal or neonatal outcome after an intervention in the antenatal period. We screened the studies and extracted the data in duplicate. A meta-analysis was not possible because of the heterogeneity of the interventions and outcomes, so we performed a narrative synthesis of the included studies. RESULTS: A total of 25 studies met our inclusion criteria. These studies showed a variety of approaches toward improving antenatal care (eg, educational programs, incentive schemes, micronutrient supplementation) in different settings (home, community, or hospital-based) and with a wide variety of outcomes. Less than a quarter of the studies were randomized controlled trials, and many were single-site or reported only short-term outcomes. All studies reported having made a positive impact on antenatal care in some way, but only 3 provided a cost-benefit analysis to support implementation. None of these studies focused on the most remote communities in Nepal. CONCLUSION: Our systematic review found good quality evidence that micronutrient supplementation and educational interventions can bring important clinical benefits. Iron and folic acid supplementation significantly reduces neonatal mortality and maternal anemia, whereas birth preparedness classes increase the uptake of antenatal and postnatal care, compliance with micronutrient supplementation, and awareness of the danger signs in pregnancy.

Differences in maternal and early child nutritional status by offspring sex in lowland Nepal.

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

Relative power: Explaining the effects of food and cash transfers on allocative behaviour in rural Nepalese households.

We estimate the effects of antenatal food and cash transfers with women's groups on household allocative behaviour and explore whether these effects are explained by intergenerational bargaining among women. Interventions were tested in randomised-controlled trial in rural Nepal, in a food-insecure context where pregnant women are allocated the least adequate diets. We show households enrolled in a cash transfer intervention allocated pregnant women with 2-3 pp larger shares of multiple foods (versus their mothers-in-law and male household heads) than households in a control group. Households in a food transfer intervention only increased pregnant women's allocation of staple foods (by 2 pp). Intergenerational bargaining power may partly mediate the effects of the cash transfers but not food transfers, whereas household food budget and nutrition knowledge do not mediate any effects. Our findings highlight the role of intergenerational bargaining in determining the effectiveness of interventions aiming to reach and/or empower junior women.

Associations between early marriage and preterm delivery: Evidence from lowland Nepal.

OBJECTIVES: Preterm delivery (<37 weeks gestation) is the largest cause of child mortality worldwide. Marriage and pregnancy during adolescence have been associated with an increased risk of preterm delivery. We investigate independent associations of age at marriage and age at first pregnancy with preterm delivery in a cohort of women from rural lowland Nepal. METHODS: We analyzed data from 17 974 women in the Low Birth Weight South Asia Trial. Logistic regression models tested associations of age at marriage and age at first pregnancy with preterm delivery, for primigravida (n = 6 243) and multigravida (n = 11 731) women. Models were adjusted for maternal education, maternal caste, and household asset score. RESULTS: Ninety percent of participants had married at <18 years and 58% had their first pregnancy at <18 years. 20% of participants delivered preterm. Primigravida participants married at ≤14 years had higher odds of preterm delivery than those married ≥18 years, when adjusting for study design (adjusted odds ratio (aOR) 1.45, 95% CI: 1.15-1.83), confounders (aOR 1.28: 1.01-1.62) and confounders + age at pregnancy (aOR 1.29: 1.00-1.68). Associations were insignificant for multigravida women. No significant associations were observed between age at first pregnancy and preterm delivery. DISCUSSION: In this population, early marriage, rather than pregnancy, is a risk factor for preterm delivery. We hypothesize that psychological stress, a driver of preterm delivery which is increased among those marrying young, rather than physiological immaturity, drives this association. Further research into the psychological consequences of child marriage in Nepal is needed.

Comprehensive analysis of the association of seasonal variability with maternal and neonatal nutrition in lowland Nepal.

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

Policies and actions to reduce maternal mortality in Nepal: perspectives of key informants.

Nepal made impressive progress in reducing maternal mortality until 2015. Since then, progress has stagnated, coinciding with Nepal's transition to a federation with significant devolution in health management. In this context, we conducted key informant interviews (KII) to solicit perspectives on policies responsible for the reduction in maternal mortality, reasons for the stagnation in maternal mortality, and interventions needed for a faster decline in maternal mortality. We conducted 36 KIIs and analysed transcripts using standard framework analysis methods. The key informants identified three policies as the most important for maternal mortality reduction in Nepal: the Safe Motherhood Policy, Skilled Birth Attendant Policy, and Safe Abortion Policy. They opined that policies were adequate, but implementation was weak and ineffective, and strategies needed to be tailored to the local context. A range of health system factors, including poor quality of care, were identified by key informants as underlying the stagnation in Nepal's maternal mortality ratio, as well as a few demand-side aspects. According to key informants, to reduce maternal deaths further Nepal needs to ensure that the current family planning, birth preparedness, financial incentives, free delivery services, abortion care, and community post-partum care programmes reach marginalised and vulnerable communities. Facilities offering comprehensive emergency obstetric care need to be accessible, and in hill and mountain areas, access could be supported by establishing maternity waiting homes. Social accountability can be strengthened through social audits, role models, and empowerment of health and management committees.

Maternal physical, socioeconomic, and demographic characteristics and childbirth complications in rural lowland Nepal: Applying an evolutionary framework to understand the role of phenotypic plasticity.

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

Quantifying the association of natal household wealth with women's early marriage in Nepal.

BACKGROUND: Women's early marriage (<18 years) is a critical global health issue affecting 650 million women worldwide. It is associated with a range of adverse maternal physical and mental health outcomes, including early childbearing, child undernutrition and morbidity. Poverty is widely asserted to be the key risk factor driving early marriage. However, most studies do not measure wealth in the natal household, but instead, use marital household wealth as a proxy for natal wealth. Further research is required to understand the key drivers of early marriage. METHODS: We investigated whether natal household poverty was associated with marrying early, independently of women's lower educational attainment and broader markers of household disadvantage. Data on natal household wealth (material asset score) for 2,432 women aged 18-39 years was used from the cluster-randomized Low Birth Weight South Asia Trial in lowland rural Nepal. Different early marriage definitions (<15, <16, <17 and <18 years) were used because most of our population marries below the conventional 18-year cut-off. Logistic mixed-effects models were fitted to estimate the probabilities, derived from adjusted Odds Ratios, of (a) marrying at different early ages for the full sample and for the uneducated women, and (b) being uneducated in the first place. RESULTS: Women married at median age 15 years (interquartile range 3), and only 18% married ≥18 years. Two-thirds of the women were entirely uneducated. We found that, rather than poverty, women's lower education was the primary factor associated with early marriage, regardless of how 'early' is defined. Neither poverty nor other markers of household disadvantage were associated with early marriage at any age in the uneducated women. However, poverty was associated with women being uneducated. CONCLUSION: When assets are measured in the natal household in this population, there is no support for the conventional hypothesis that household poverty is associated with daughters' early marriage, but it is associated with not going to school. We propose that improving access to free education would both reduce early marriage and have broader benefits for maternal and child health and gender equality.

A cross-sectional study to evaluate antenatal care service provision in 3 hospitals in Nepal.

BACKGROUND: Globally, many mothers and their babies die during pregnancy and childbirth. A key element of optimizing outcomes is high-quality antenatal care. The Government of Nepal has significantly improved antenatal care and health outcomes through high-level commitment and investment; however, only 69% of patients attend the 4 recommended antenatal appointments. OBJECTIVE: This study aimed to evaluate the quality and perceptions of antenatal care in Nepal to understand compliance with the Nepalese standards. STUDY DESIGN: This cross-sectional study was conducted at a tertiary referral and private hospital in Kathmandu and a secondary hospital in Makwanpur, Nepal. The study recruited 538 female inpatients on postnatal wards during the 2-week data collection period from May 2019 to June 2019. A review of case notes and verbal survey of women to understand the pregnancy information they received and their satisfaction with antenatal care were performed. We created a summary score of the completeness of antenatal care services received ranging from 0 to 50 (50 indicating complete conformity with standards) and investigated the determinants of attending 4 antenatal care visits and patient satisfaction. RESULTS: The median antenatal care attendance was 4 visits at the secondary and referral hospitals and 8 visits at the private hospital. However, 24% of the patients attended <4 visits. Furthermore, 117 of 538 patients (22%) attended the first-trimester visit, and 65 of 538 patients (12%) attended visits at all points recommended in the standards. More than 90% of the women had blood pressure monitoring, hemoglobin estimation, blood grouping and Rhesus typing, and HIV and syphilis screening. Approximately 50% of the women had urinalysis at every visit (interquartile range, 20-100). Moreover, 509 of 538 patients (95%) reported receiving pregnancy information, but retention was variable: 509 of 538 patients (93%) received some information about danger signs, 290 of 502 patients (58%) remembered headaches, and 491 of 502 patients (98%) remembered fluid leaking. The antenatal care completeness score revealed that the private hospital offered the most complete clinical services (mean, 28.7; standard deviation, 7.1) with the secondary hospital performing worst (mean, 19.1; standard deviation, 7.1). The factors influencing attendance at 4 antenatal care visits in the multivariable model were beginning antenatal care in the first trimester of pregnancy (odds ratio, 2.74; 95% confidence interval, 1.36-5.52) and having a lower level of education (no school: odds ratio, 0.46 [95% confidence interval, 0.23-0.91]; grades 1-5: odds ratio, 0.49 [95% confidence interval, 0.26-0.92]). Overall, 303 of 538 women (56%) were satisfied with their antenatal care. The multivariable analysis revealed that satisfaction was more likely in women attending the private hospital than in women attending the referral hospital (odds ratio, 3.63; 95% confidence interval, 1.68-7.82) and lower in women who felt the antenatal care facilities were not adequate (odds ratio, 0.35; 95% confidence interval, 0.21-0.63) and who wanted longer antenatal appointments (odds ratio, 0.5; 95% confidence interval, 0.33-0.75). CONCLUSION: Few women achieved full compliance with the Nepali antenatal care standards; however, some services were delivered well. To improve, each antenatal contact needs to meet its clinical aims and be respectful. To achieve this communication and counseling training for staff, investment in health promotion and delivery of core services are needed. It is important that these interventions address key issues, such as attendance in the first trimester of pregnancy, improving privacy and optimizing communication around danger signs. However, they must be designed alongside staff and service users and their efficacy tested before widespread investment or implementation.

Independent associations of women's age at marriage and first pregnancy with their height in rural lowland Nepal.

OBJECTIVES: In many South Asian communities, the majority of women are married during adolescence and reproduce before 20 years. Early reproduction may adversely affect maternal nutrition and linear growth, however whether early marriage has similar effects is unknown. Shorter women might also be preferentially chosen for earlier marriage. We hypothesized that early marriage and early pregnancy may each be associated with women's shorter height, independent of any selection effects. MATERIALS AND METHODS: We analyzed cross-sectional data on 7,146 women aged 20-30 years from rural lowland Nepal. Linear regression models tested associations of early marriage and early reproduction with height, adjusting for women's education and husbands' characteristics (education and wealth) that might index preferential selection of short young women for marriage. RESULTS: Median ages at marriage and first pregnancy were 15 and 18 years, respectively, with 20% pregnant <16 years. Both early marriage and early pregnancy were independently associated with shorter stature, accounting for a decrement of 1.4 cm, which decreased to 1 cm after adjusting for women's education. Effects of early marriage and reproduction persisted after adjusting for the tendency of poorer and less educated men to marry young and short women, indicating a role for social selection. DISCUSSION: The decrements in height associated with early marriage and reproduction are indicative of broader adverse effects on maternal metabolism during a "critical period" of growth and maturation in the life-course of women. Although the magnitudes of effect are relatively small, they affect large numbers of women in this population.

Equity implications of rice fortification: a modelling study from Nepal.

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

The association of maternal nutrition and children's pre-primary experience with over-age attendance in secondary school: evidence from lowland Nepal.

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

Sustainability of community-based women's groups: reflections from a participatory intervention for newborn and maternal health in Nepal.

Participatory community-based women's group interventions have been successful in improving maternal and newborn survival. In rural Makwanpur, Nepal, exposure to these Participatory Learning and Action groups resulted in a thirty-percent reduction in neonatal mortality rate and significantly fewer maternal deaths. It is often theorised that participatory approaches are more likely to be sustained than top-down approaches, but this is rarely evaluated after the withdrawal of external support. We sought to understand how participatory learning and action (PLA) groups in Makwanpur fared after the supporting non-governmental organisation withdrew their support as well as factors affecting their sustainability. We used mixed methods, conducting a cross-sectional survey of 239 groups, thirty focus group discussions with group members and thirty key informant interviews within twelve-seventeen months after support was withdrawn. Eighty percent of groups were still active which suggests that PLA groups have a high chance of being sustained over time. Groups were more likely to be sustained if the group had local importance and members continued to acquire new knowledge. However, the participatory nature of the group and local embeddedness were not enough to sustain all groups. They also needed leadership capacity, a unifying activity such as a fund, and a strong belief in the value of their meeting to sustain. These key factors should be considered when seeking to enable sustainability of participatory interventions.

Associations of stunting at 2 years with body composition and blood pressure at 8 years of age: longitudinal cohort analysis from lowland Nepal.

BACKGROUND: Stunting remains a very common form of child malnutrition worldwide, particularly in South Asian populations. There is poor understanding of how it develops and how it is associated with subsequent phenotype. SUBJECTS/METHODS: We used data from a longitudinal cohort of children (n = 841) in lowland Nepal to investigate associations of stunting at 2 years with maternal traits and early growth patterns, and with body size and composition, kidney dimensions by ultrasound, lung function by spirometry and blood pressure (BP) at 8 years. RESULTS: Compared to non-stunted children, children stunted at 2 years came from poorer families and had shorter, lighter mothers. They tended to have higher birth order, were born smaller, and remained shorter, lighter and thinner at 8 years. They had lower leg length, lean and fat masses, smaller kidneys, and reduced lung function (all p < 0.0001). These differences persisted with smaller magnitude after adjusting for current height, maternal height and education, family assets and birth order. Stunting was not associated with BP. DISCUSSION: Stunting developed on an inter-generational timescale in this population and its risk increased with birth order. At 8 years, children stunted at 2 years had deficits in tissue masses and some aspects of physical function that were only partially attributable to their persisting short height and maternal phenotype. This suggests that the early stunting is associated with greater deficits in long-term outcomes than would be expected from the persistent short stature alone.