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.

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

INTRODUCTION: Perinatal mortality rate is a sensitive indicator of quality of care provided to women in pregnancy, at and after child birth and to the newborns in the first week of life. Regular perinatal audit would help in identifying all the factors that play a role in causing perinatal deaths and thus help in appropriate interventions to reduce avoidable perinatal deaths. AIMS AND OBJECTIVES: This study was carried out to determine perinatal mortality rate (PMR) and the factors responsible for perinatal deaths at KMCTH in the two year period from November 2003 to October 2005 (Kartik 2060 B.S. to Ashoj 2062). METHODOLOGY: This is a prospective study of all the still births and early neonatal deaths in KMCTH during the two year period from November 2003 to October 2005. Details of each perinatal death were filled in the standard perinatal death audit forms of the Department of Pediatrics, KMCTH. Perinatal deaths were analyzed according to maternal characteristics like maternal age, parity, type of delivery and fetal characteristics like sex, birth weight and gestational age and classify neonatal deaths according to Wigglesworth's classification and comparison made with earlier similar study. RESULTS: Out of the 1517 total births in the two year period, 22 were still births (SB) and 10 were early neonatal deaths (ENND). Out of the 22 SB, two were of < 1 kg in weight and out of 10 ENND, one was of <1 kg. Thus, perinatal mortality rate during the study period was 19.1 and extended perinatal mortality rate was 21.1 per 1000 births. The important causes of perinatal deaths were extreme prematurity, birth asphyxia, congenital anomalies and associated maternal factors like antepartum hemorrhage and most babies were of very low birth weight. According to Wigglesworth's classification, 43.8% of perinatal deaths were in Group I, 12.5% in Group II, 28.1% in Group III, 12.5% in Group IV and 12.5% in Group V. DISCUSSION: The perinatal death audit done in KMCTH for 1 year period from September 2002 to August 2003 showed perinatal mortality rate of 30.7 and extended perinatal mortality rate of 47.9 per 1000 births. There has been a significant reduction in the perinatal mortality rate in the last 2 years at KMCTH. Main reasons for improvement in perinatal mortality rate were improvement in care of both the mothers and the newborns and the number of births have also increased significantly in the last 2 years without appropriate increase in perinatal deaths. CONCLUSION: Good and regular antenatal care, good care at the time of birth including appropriate and timely intervention and proper care of the sick neonates are important in reducing perinatal deaths. Prevention of preterm births, better care and monitoring during the intranatal period and intensive care of low birth weight babies would help in further reducing perinatal deaths. Key words: Perinatal mortality rate (PMR), still births, early neonatal death (ENND), Total perinatal death (PND).

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.

Prevalence of childhood and adolescent disabilities in rural Nepal.

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

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

BACKGROUND: Verbal autopsy is a method to diagnose possible cause of death by analyzing factors associated with death through detailed questioning. This study is a part of the operational research program in electoral constituency no. 2 (EC 2) of Arghakhanchi district by MIRA and HealthRight International. METHODS: Two day essential newborn care training followed by one day perinatal verbal autopsy training and later one day refresher verbal autopsy training was given for health staff of EC 2 of Arghakhanchi district in two groups. Stillbirths of >22wks or > 500 gms and Early neonatal deaths (newborns died within7 days of life) were included in this study. The Nepal Government approved verbal autopsy forms were used for performing autopsies. Perinatal deaths were classified according to Wigglesworth's Classification. Causes of Perinatal deaths were analyzed. Data were analyzed in the form of frequencies and tabulation in SPSS 16 . RESULTS: There were 41 cases of perinatal deaths (PND) were identified. Among them, 37 PNDs were from Arghakhanchi district hospital, 2 PNDs from Thada PHC, and one PND each from Subarnakhal and Pokharathok HPs. Among the 41 PNDs, 26 were stillbirths (SB) and 15 were early neonatal deaths (ENND). The perinatal mortality rate (PMR) of Arghakhanchi district hospital was 32.2 per 1,000 births and neonatal mortality rate (NMR) was 9.8 per 1,000 live births. Out of 26 stillbirths, 54% (14) were fresh SBs and 46% (12) were macerated stillbirths. The most common cause of stillbirth was obstetric complications (47%) where as birth asphyxia (53%) was the commonest cause of ENND. According to Wigglesworth's classification of perinatal deaths, Group IV (40%) was the commonest cause in the health facilities. CONCLUSIONS: Obstetric complication was the commonest cause of stillbirth and birth asphyxia was the commonest cause of early neonatal death. This study highlighted the need for regular antenatal check-ups and proper intrapartum fetal monitoring with timely and appropriate intervention to reduce the incidence of stillbirths and intrauterine asphyxia.

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

BACKGROUND: As part of the Partnership for Maternal and Newborn Health Project (PMNH), HealthRight International collaborated with Mother and Infant Research Activities (MIRA) to conduct operations research in Arghakhanchi district of Nepal to explore the intervention impact of strengthening health facility, improving community facility linkages along with Community Based Newborn Care Program (CB-NCP) on Maternal Neonatal Care (MNC) service quality, utilization, knowledge and care seeking behavior. METHODS: This was a quasi-experimental study. Siddahara, Pokharathok, Subarnakhal,Narpani Health Posts (HPs) and Thada Primary Health Care Center(PHCC)in Electoral Constituency-2 were selected as intervention sites and Arghatosh, ,Argha, Khana, Hansapur HPs and Balkot PHCC in Electoral Constituency-1 were chosen as controls. The intervention started in February 2011 and was evaluated in August 2013. To compare MNC knowledge and practice in the community, mothers of children aged 0-23 months were selected from the corresponding Village Development Committees(VDCs) by a two stage cluster sampling design during both baseline (July 2010) and endline (August, 2013) assessments. The difference in difference analysis was used to understand the intervention impact. RESULTS: Local resource mobilization for MNC, knowledge about MNC and service utilization increased in intervention sites. Though there were improvements, many effects were not significant. CONCLUSIONS: Extensive trainings followed by reviews and quality monitoring visits increased the knowledge, improved skills and fostered motivation of health facility workers for better MNC service delivery. MNC indicators showed an upsurge in numbers due to the synergistic effects of many interventions.

Neurobrucellosis in children.

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

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

OBJECTIVE: To test the hypothesis that stunted Nepalese children have an altered stress response system when compared with matched nonstunted children in response to a battery of psychological tests. DESIGN: Case-control study. SETTING: Poor urban areas of Kathmandu, Nepal. SUBJECTS: A total of 64 stunted (less than -2 s.d. height-for-age) children compared with 64 nonstunted (> -1s.d. height-for-age) schoolchildren between 8 and 10 y old matched for school and sex. METHODS: A psychological test session was administered, which included mental arithmetic and two tests of working memory. Salivary cortisol samples were obtained at five points during testing, and heart rate was measured during testing and also at baseline. Salivary cortisol samples were also obtained once early in the morning. Hemoglobin was assessed at the testing session, and extensive data were obtained on the social background of the children's families. RESULTS: Stunted Nepalese children showed a blunted physiologic response (salivary cortisol and heart rate) to psychological stressors (P<0.05) when compared with nonstunted children, but were not different from the nonstunted children in baseline measures, when controlling for social background. The two groups were not different in terms of social background. CONCLUSIONS: These findings suggest that childhood growth retardation may be associated with changes in physiological arousal, and that stunting could be associated with hyporesponsivity in response to psychological stress.

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

AIMS: To describe the pattern of hypothermia and cold stress after delivery among a normal neonatal population in Nepal; to provide practical advice for improving thermal care in a resource limited maternity hospital. METHODS: The principal government funded maternity hospital in Kathmandu, Nepal, with an annual delivery rate of 15,000 (constituting 40% of all Kathmandu Valley deliveries), severe resource limitations (annual budget Pounds 250,000), and a cold winter climate provided the setting. Thirty five healthy term neonates not requiring special care were enrolled for study within 90 minutes of birth. Continuous ambulatory temperature monitoring, using microthermistor skin probes for forehead and axilla, a flexible rectal probe, and a black ball probe placed next to the infant for ambient temperature, was carried out. All probes were connected to a compact battery powered Squirrel Memory Logger, giving a temperature reading to 0.2 degree C at five minute intervals for 24 hours. Severity and duration of hypothermia, using cutoff values of core temperature less than 36 degrees C, 34 degrees C, and 32 degrees C; and cold stress, using cutoff values of skin-core (forehead-axilla) temperature difference greater than 3 degrees C and 4 degrees C were the main outcome measures. RESULTS: Twenty four hour mean ambient temperatures were generally lower than the WHO recommended level of 25 degrees C (median 22.3 degrees C, range 15.1-27.5 degrees C). Postnatal hypothermia was prolonged, with axillary core temperatures only reaching 36 degrees C after a mean of 6.4 hours (range 0-21.1; SD 4.6). There was persistent and increasing cold stress over the first 24 hours with the core-skin (axillary-forehead) temperature gap exceeding 3 degrees C for more than half of the first 24 hours. CONCLUSIONS: Continuous ambulatory recording identifies weak links in the "warm chain" for neonates. The severity and duration of thermal problems was greater than expected even in a hospital setting where some of the WHO recommendations had already been implemented.

Neonatal hypoglycaemia in Nepal 1. Prevalence and risk factors.

AIMS: To measure the prevalence of hypoglycaemia among newborn infants in Nepal, where classic risk factors prevail, and to evaluate their importance. METHODS: A cross sectional study was done of 578 term newborn infants aged 0 to 48 hours on the postnatal wards of a government maternity hospital in Kathmandu, with unmatched case-control analysis of risk factors for moderate hypoglycaemia (less than 2.0 mmol /l). RESULTS: Two hundred and thirty eight (41%) newborn infants had mild (less than 2.6 mmol/l) and 66 (11%) moderate hypoglycaemia. Significant independent risk factors for moderate hypoglycaemia included postmaturity (OR 2.62), birthweight under 2.5 kg (OR 2.11), small head size (OR 0.59), infant haemoglobin >210 g/l (OR 2.77), and raised maternal thyroid stimulating hormone (TSH) (OR 3.08). Feeding delay increased the risk of hypoglycaemia at age 12-24 hours (OR 4.09). Disproportionality affected the risk of moderate hypoglycaemia: lower with increasing ponderal index (OR 0.29), higher as the head circumference to birthweight ratio increased (OR 1.41). Regression expressing blood glucose concentration as a continuous variable revealed associations with infant haemoglobin (negative) and maternal haemoglobin (positive), but no other textbook risk factors. CONCLUSIONS: Neonatal hypoglycaemia is more common in a developing country, but may not be a clinical problem unless all fuel availability is reduced. Some textbook risk factors, such as hypothermia, disappear after controlling for confounding variables. Early feeding could reduce moderate hypoglycaemia in the second 12 hours of life. The clinical significance of raised maternal TSH and maternal anaemia as prenatal risk factors requires further research.

Neonatal hypoglycaemia in Nepal 2. Availability of alternative fuels.

AIMS: To study early neonatal metabolic adaptation in a hospital population of neonates in Nepal. METHODS: A cross sectional study was made of 578 neonates, 0 to 48 hours after birth, in the main maternity hospital in Kathmandu. The following clinical and nutritional variables were assessed: concentrations and age profiles of blood glucose, hydroxybutyrate, lactate, pyruvate, free fatty acids (FFA) and glycerol; associations between alternative fuel levels and hypoglycaemia; and regression of possible risk factors for ketone availability. RESULTS: Risk factors for impaired metabolic adaptation were common, especially low birthweight (32%), feeding delays, and cold stress. Blood glucose and ketones rose with age, but important age effects were also found for risk factors like hypothermia, thyroid hormone activities, and feeding practices. Alternative fuel concentrations, except FFA, were significantly reduced in infants with moderate hypoglycaemia during the first 48 hours after birth. Unlike earlier studies, small for gestational age (SGA) infants had significantly higher hydroxybutyrate:glucose ratios which suggested counter regulatory ketogenesis. Hypoglycaemic infants were not hyperinsulinaemic. Regression analysis showed risk factors for impaired counter regulation which included male and large infants, hypothermia, and poorer infant thyroid function. SGA infants and those whose mothers had received no antenatal care had increased counter regulation. CONCLUSIONS: Alternative fuels are important in the metabolic assessment of neonates, and they might provide effective cerebral metabolism even during moderate hypoglycaemia. Hypoglycaemic infants generally had lower concentrations of alternative fuels through either reduced availability or increased consumption. SGA and post term infants increased counter regulatory ketogenesis with early neonatal hypoglycaemia, but hypothermia, male gender, and low infant T4 were associated with impaired counter regulation after birth.

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

AIMS: To compare two cotside methods of blood glucose measurement (HemoCue and Reflolux II) against a standard laboratory method for the detection of neonatal hypoglycaemia in a developing country maternity hospital where hypoglycaemia is common. METHODS: 94 newborn infants and 75 of their mothers had blood glucose assessed on the same venous sample using three different methods in the Special Care Baby Unit and postnatal wards, Prasuti Griha Maternity Hospital, Kathmandu, Nepal: HemoCue and Reflolux II at the cotside; Roche Ultimate glucose oxidase method (GOM) in the laboratory. RESULTS: The mean (SD) values for blood glucose in newborn infants were GOM 2.5 (1.1) mmol/l; Reflolux II 2.1 (0.9); and HemoCue 4.2 (1.2). For mothers the values were GOM 5.3 (1.2) mmol/l; Reflolux II 3.6 (1.2); and HemoCue 5.6 (1.0). Bland-Altman plots showed that Reflolux II consistently underreads GOM blood glucose in neonates by 0.5 mmol/l (SD 0.7) and that HemoCue overreads glucose by 1.7 mmol/l (SD 0.8). For the detection of hypoglycaemia (< 2.0 mmol/l), Reflolux II achieved a sensitivity of 83%, a specificity of 62%, and a likelihood ratio of 2.2. HemoCue produced a sensitivity of 0% and a specificity of 100% using measured values. If 2.0 mmol were subtracted from all Hemocue values this rose to 81% and 68% and a likelihood ratio of 2.5. CONCLUSION: Although more accurate than Reflolux II for the measurement of blood glucose in mothers, HemoCue overreads glucose concentrations in neonates and is therefore potentially dangerous as a screening method for neonatal hypoglycaemia. Reflolux II is useful as a screening method for high risk infants (low birthweight, post-term) and could achieve a post-test probability of detecting hypoglycaemia in a high risk setting like Nepal of 50-60%.

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

OBJECTIVE: To determine the risk factors for neonatal encephalopathy among term infants in a developing country. DESIGN: Unmatched case-control study. SETTING: Principal maternity hospital of Kathmandu, Nepal. SUBJECTS: All 131 infants with neonatal encephalopathy from a population of 21 609 infants born over an 18 month period, and 635 unmatched infants systematically recruited over 12 months. MAIN OUTCOME MEASURES: Adjusted odds ratio estimates for antepartum and intrapartum risk factors. RESULTS: The prevalence of neonatal encephalopathy was 6.1 per 1,000 live births of which 63% were infants with moderate or severe encephalopathy. The risk of death from neonatal encephalopathy was 31%. The risk of neonatal encephalopathy increased with increasing maternal age and decreasing maternal height. Antepartum risk factors included primiparity (odds ratio 2.0) and non-attendance for antenatal care (2.1). Multiple births were at greatly increased risk (22). Intrapartum risk factors included non-cephalic presentation (3.4), prolonged rupture of membranes (3.8), and various other complications. Particulate meconium was strongly associated with encephalopathy (18). Induction of labour with oxytocin was associated with encephalopathy in 12 of 41 deliveries (5.7). Overall, 78 affected infants (60%) compared with 36 controls (6%) either had evidence of intrapartum compromise or were born after an intrapartum difficulty likely to result in fetal compromise. A concentration of maternal haemoglobin of less than 8.0 g/dl in the puerperium was significantly associated with encephalopathy (2.5) as was a maternal thyroid stimulating hormone concentration greater than 5 mIU/l (2.1). CONCLUSIONS: Intrapartum risk factors remain important for neonatal encephalopathy in developing countries. There is some evidence of a protective effect from antenatal care. The use of oxytocin in low income countries where intrapartum monitoring is suboptimal presents a major risk to the fetus. More work is required to explore the association between maternal deficiency states and neonatal encephalopathy.

PIP: This unmatched case-control study determined the risk factors for neonatal encephalopathy among term infants in Kathmandu, Nepal. Study participants included 131 infants with neonatal encephalopathy born between January 1995 and July 1996, and 635 unmatched infants systematically recruited over 12 months. The prevalence of neonatal encephalopathy was 6.1% per 1000 live births, of which 63% were infants with moderate encephalopathy. Antepartum risk factors included multiple births (odds ratio, OR = 22), primiparity (OR = 2.0), and nonattendance for antenatal care (OR = 2.1). Intrapartum risk factors were particulate meconium (OR = 18), noncephalic presentation (OR = 3.4), prolonged rupture of membranes (OR = 3.8), and other complications. In addition, induction of labor with oxytocin was associated with encephalopathy in 12 of 41 deliveries (OR = 5.7). Overall, 78 affected infants (60%) compared with 36 controls (6%) either had evidence of intrapartum compromise or were born after an intrapartum difficulty likely to result in fetal compromise. Moreover, maternal hemoglobin concentration 8.0 g/dl (OR = 2.5) and thyroid stimulating hormone 5 ml U/l (OR = 2.1) were associated with encephalopathy. Intrapartum risk factors remain important for neonatal encephalopathy in developing countries. There is some evidence of a protective effect from antenatal care. The use of oxytocin in low-income countries where intrapartum monitoring is suboptimal presents a major risk to the fetus. Further studies are required to explore the association between maternal deficiency states and neonatal encephalopathy.

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

OBJECTIVES: To evaluate impact of postnatal health education for mothers on infant care and postnatal family planning practices in Nepal. DESIGN: Randomised controlled trial with community follow up at 3 and 6 months post partum by interview. Initial household survey of study areas to identify all pregnant women to facilitate follow up. SETTING: Main maternity hospital in Kathmandu, Nepal. Follow up in urban Kathmandu and a periurban area southwest of the city. SUBJECTS: 540 mothers randomly allocated to one of four groups: health education immediately after birth and three months later (group A), at birth only (group B), at three months only (group C), or none (group D). INTERVENTIONS: Structured baseline household questionnaire; 20 minute, one to one health education at birth and three months later. MAIN OUTCOME MEASURES: Duration of exclusive breast feeding, appropriate immunisation of infant, knowledge of oral rehydration solution and need to continue breast feeding in diarrhoea, knowledge of infant signs suggesting pneumonia, uptake of postnatal family planning. RESULTS: Mothers in groups A and B (received health education at birth) were slightly more likely to use contraception at six months after birth compared with mothers in groups C and D (no health education at birth) (odds ratio 1.62, 95% confidence interval 1.06 to 2.5). There were no other significant differences between groups with regards to infant feeding, infant care, or immunisation. CONCLUSIONS: Our findings suggest that the recommended practice of individual health education for postnatal mothers in poor communities has no impact on infant feeding, care, or immunisation, although uptake of family planning may be slightly enhanced.

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

OBJECTIVE: To evaluate the relationship between an Apgar score of three or less at one minute of life and the subsequent risk of developing neonatal encephalopathy (NE). DESIGN: Prospective. SETTING: The principal maternity hospital of Kathmandu, Nepal, a low income country, where over 50% of the local population deliver. METHODS: All liveborn infants over a 12 month period with a birthweight of 500 g or more were assessed by the Apgar scoring system at one minute of age. All term infants with neurological abnormalities presenting in the first day of life were systematically examined and described according to a conventionally defined encephalopathy grading system. Major congenital malformations and neonatal infections were excluded. RESULTS: Over 12 months there were 14,771 total births of a weight of 500 g or more of which 14,371 were live births and 400 were stillbirths. Of 734 infants with 1 min Apgar of three or less, 91 developed NE. The positive and negative predictive values of 1 min Apgar of three or less for NE were 11.4% and 99.9%, respectively. The probability of developing NE rose from 0.6% (amongst all infants born at this hospital) to 11.2% (amongst infants born with a one minute Apgar of three or less). CONCLUSIONS: An Apgar score of 3 or less at one minute is a useful screening test for clinically significant birth asphyxia (NE). It overestimates by eight fold the scale of the birth asphyxia problem, but identifies a high risk group requiring further observation of their neurological condition.

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.