Human rights violations among sexual and gender minorities in Kathmandu, Nepal: a qualitative investigation

BACKGROUND: Nepal has experienced sporadic reports of human rights violations among sexual and gender minorities. Our objective was to identify a range of human rights that are enshrined in international law and/or are commonly reported by sexual and gender minority participants in Kathmandu, to be nonprotected or violated. METHODS: In September 2009 three focus group discussions were conducted by trained interviewers among a convenience sample of sexual and gender minority participants in Kathmandu Nepal. The modified Delphi technique was utilized to elicit and rank participant-generated definitions of human rights and their subsequent violations. Data was analyzed independently and cross checked by another investigator. RESULTS: Participants (n = 29) reported experiencing a range of human rights violations at home, work, educational, health care settings and in public places. Lack of adequate legal protection, physical and mental abuse and torture were commonly reported. Access to adequate legal protection and improvements in the family and healthcare environment were ranked as the most important priority areas. CONCLUSIONS: Sexual and gender minorities in Nepal experienced a range of human rights violations. Future efforts should enroll a larger and more systematic sample of participants to determine frequency, timing, and/or intensity of exposure to rights violations, and estimate the population-based impact of these rights violations on specific health outcome

Risk and burden of adverse intrapartum-related outcomes associated with non-cephalic and multiple birth in rural Nepal: a prospective cohort study

Objectives Intrapartum-related complications are the second leading cause of neonatal death worldwide. We estimate the community-level risk and burden of intrapartum-related fetal/neonatal mortality and morbidity associated with non-cephalic and multiple birth in rural Sarlahi District, Nepal. Design Community-based prospective cohort study. Setting Rural Sarlahi District, Nepal. Participants Pregnant women residing in the study area. Methods We collected data on maternal background characteristics, conditions during labour and delivery, fetal presentation and multiple birth during home visits. We ran log-binomial regression models to estimate the associations between non-cephalic/multiple births and fresh stillbirth, early neonatal mortality and signs of neonatal encephalopathy, respectively, and calculated the per cent attributable fraction. To better understand the context under which these adverse birth outcomes are occurring, we also collected data on maternal awareness of non-cephalic presentation and multiple gestation prior to delivery. Primary outcome measures Risk of experiencing fresh stillbirth, early neonatal encephalopathy and early neonatal mortality associated with non-cephalic and multiple birth, respectively. Results Non-cephalic presentation had a particularly high risk of fresh stillbirth (aRR 12.52 (95% CI 7.86 to 19.95), reference: cephalic presentation). 20.2% of all fresh stillbirths were associated with non-cephalic presentation. For multiple births, there was a fourfold increase in early neonatal mortality (aRR: 4.57 (95% CI 1.44 to 14.50), reference: singleton births). 3.4% of early neonatal mortality was associated with multiple gestation. Conclusions Globally and in Nepal, a large percentage of stillbirths and neonatal mortality is associated with intrapartum-related complications. Despite the low incidence of non-cephalic and multiple birth, a notable proportion of adverse intrapartum-related outcomes is associated with these conditions. As the proportion of neonatal deaths attributable to intrapartum-related complications continues to rise, there is a need to investigate how best to advance diagnostic capacity and management of these conditions. Trial registration number NCT01177111; pre-results

Risk and Burden of Adverse Intrapartum-Related Outcomes Associated with Non-Cephalic and Multiple Birth in Rural Nepal: a Prospective Cohort Study.

OBJECTIVES: Intrapartum-related complications are the second leading cause of neonatal death worldwide. We estimate the community-level risk and burden of intrapartum-related fetal/neonatal mortality and morbidity associated with non-cephalic and multiple birth in rural Sarlahi District, Nepal. DESIGN: Community-based prospective cohort study. SETTING: Rural Sarlahi District, Nepal. PARTICIPANTS: Pregnant women residing in the study area. METHODS: We collected data on maternal background characteristics, conditions during labour and delivery, fetal presentation and multiple birth during home visits. We ran log-binomial regression models to estimate the associations between non-cephalic/multiple births and fresh stillbirth, early neonatal mortality and signs of neonatal encephalopathy, respectively, and calculated the per cent attributable fraction. To better understand the context under which these adverse birth outcomes are occurring, we also collected data on maternal awareness of non-cephalic presentation and multiple gestation prior to delivery. PRIMARY OUTCOME MEASURES: Risk of experiencing fresh stillbirth, early neonatal encephalopathy and early neonatal mortality associated with non-cephalic and multiple birth, respectively. RESULTS: Non-cephalic presentation had a particularly high risk of fresh stillbirth (aRR 12.52 (95% CI 7.86 to 19.95), reference: cephalic presentation). 20.2% of all fresh stillbirths were associated with non-cephalic presentation. For multiple births, there was a fourfold increase in early neonatal mortality (aRR: 4.57 (95% CI 1.44 to 14.50), reference: singleton births). 3.4% of early neonatal mortality was associated with multiple gestation. CONCLUSIONS: Globally and in Nepal, a large percentage of stillbirths and neonatal mortality is associated with intrapartum-related complications. Despite the low incidence of non-cephalic and multiple birth, a notable proportion of adverse intrapartum-related outcomes is associated with these conditions. As the proportion of neonatal deaths attributable to intrapartum-related complications continues to rise, there is a need to investigate how best to advance diagnostic capacity and management of these conditions. TRIAL REGISTRATION NUMBER: NCT01177111; pre-results

Validity of home-based sonographic diagnosis of obstetric risk factors by auxiliary nurse midwives in rural Nepal

Background Approximately 2·3 million fetal, neonatal, or maternal deaths occur annually during the intrapartum period or on the day of birth. Several risk factors for intrapartum-related complications require ultrasonography for accurate diagnosis, but sonographic services are scarce in low-resource settings. In this study, we aimed to assess the feasibility of community-based ultrasonography conducted by auxiliary nurse midwives to identify basic obstetric risk factors, in rural Sarlahi District, Nepal. We aimed to assess the validity at which these health workers can detect noncephalic position, multiple gestation, and placenta previa and to explore whether sonographic diagnosis could improve outcomes for women with these high-risk conditions. Methods Three auxiliary nurse midwives (ANM) received two 1-week ultrasound trainings at Tribhuvan University Teaching Hospital in Kath mandu, Nepal. Women at 32 weeks’ or more gestation were enrolled in the study, and received ultrasonography from the ANMs during home visits. ANMs used ultrasonography to identify non-cephalic position, multiple gestation, and placenta previa. Images were saved and later reassessed by gold standard ultrasonographers to determine the validity of the ANM assessment. We also compared adverse outcomes in noncephalic or multiple gestation births from the study group with those in a comparison group of women who did not receive ultrasonography from our study, but the study was not powered to detect a difference. Findings We collected data from 815 women. The kappa statistics for diagnosis of non-cephalic position were 0·92, 0·98, and 0·94, respectively, for the three ANMs against the gold standard. Sensitivity, specificity, positive predictive value, and negative predictive value were between 90% and 100% for all ANMs. For multiple gestation pregnancies (n=6), the ANMs were in perfect agreement with both the gold standard reading and maternal postpartum self-report. Two cases of placenta previa were detected, and the gold standard was in agreement with both. There were 4 adverse outcomes out of 19 women (21%) with non-cephalic or multiple gestation pregnancies in the study group compared with 10 out of 36 (28%) in the comparison group. This difference was not significant (p=0·586). Interpretation Our findings suggest that it is feasible for ANMs to conduct ultrasonography to identify basic obstetric risk factors in low-income settings. The difference in birth outcomes in non-cephalic and multiple births, comparing those antenatally diagnosed by ultrasound and those who were not, was not significant; the sample size was too small to detect a diff erence. Further investigation is warranted to determine whether sonographic diagnosis of selected obstetric factors could contribute to improved care-seeking and health outcomes in low-income settings. Funding Cappsci Data for Life Award, SonoSite Soundcaring Program, National Institutes of Health/National Institute of Child Health and Human Development, Bill & Melinda Gates Foundation

Sex differences in morbidity and care-seeking during the neonatal period in rural southern Nepal

Background South Asian studies, including those from Nepal, have documented increased risk of neonatal mortality among girls, despite their early biologic survival advantage. We examined sex differences in neonatal morbidity and care-seeking behavior to determine whether such differences could help explain previously observed excess late neonatal mortality among girls in Nepal. Methods A secondary analysis of data from a trial of chlorhexidine use among neonates in rural Nepal was conducted. The objective was to examine sex differences in neonatal morbidity and care-seeking behavior for ill newborns. Girls were used as the reference group. Results Referral for care was higher during the early neonatal period (ENP: 0–7 days old) (50.7 %) than the late neonatal period (LNP: 8–28 days old) (31.3 %), but was comparable by sex. There were some significant differences in reasons for referral by sex. Boys were significantly more often referred for convulsions/stiffness, having yellow body/eyes, severe skin infection, and having at least two of the following: difficulty breathing, difficulty feeding, fever, or vomiting during the ENP. Girls were more often referred for hypothermia. During the LNP, boys were significantly more often referred for having yellow body/eyes, persistent watery stool, and severe skin infection. There were no referral types in the LNP for which girls were more often referred. Less than half of those referred at any point were taken for care (47.0 %) and referred boys were more often taken than girls (Neonatal Period OR: 1.77, 95 % CI: 1.64 - 1.91). Family composition differentially impacted the relationship between care-seeking and sex. The greatest differences were in families with only prior living girls (Pahadi - ENP OR: 1.78, 95 % CI: 1.29 - 2.45 and LNP OR: 1.51, 95 % CI: 1.03 - 2.21; Madeshi - ENP OR: 2.86, 95 % CI: 2.28 – 3.59 and LNP OR: 2.45, 95 % CI: 1.84 – 3.26). Conclusions Care-seeking was inadequate for both sexes, but ill boys were consistently more often taken for care than girls, despite comparable referral. Behavioral interventions to improve care-seeking, especially in the early neonatal period, are needed to improve neonatal survival. Addressing gender bias in care-seeking, explicitly and within interventions, is essential to reducing neonatal mortality differentials between boys and girls

Perceptions, careseeking, and experiences pertaining to non-cephalic births in rural Sarlahi District, Nepal: a qualitative study.

BACKGROUND: In low-resource settings, a significant proportion of fetal, neonatal, and maternal deaths can be attributed to intrapartum-related complications. Certain risk factors, such as non-cephalic presentation, have a particularly high risk of complications. This qualitative study describes experiences around non-cephalic births and highlights existing perceptions and care-seeking behavior specific to non-cephalic presentation in rural Sarlahi District, Nepal. METHODS: We conducted in-depth interviews with 34 individuals, including women who recently gave birth to a non-cephalic infant and female decision-makers in their households. We also conducted two focus groups with mothers (have two or more children, with at least one child under age five) and two focus groups with grandmothers in the community. RESULTS: Several women described scenes of obstructed labor and practices like provision of unspecified injections early in labor to assist with the delivery. There were reports of arduous care-seeking processes from primary health centers to tertiary facilities, and mixed quality of care among home birth attendants and facility-based health workers respectively. Very few women were aware of the fetal presentation prior to delivery, and we identified no consistent understanding among participants of the risks of and care strategies for non-cephalic births. Risk perception around non-cephalic presentation varied widely. Some participants were acutely aware of potential dangers, while others had not heard of non-cephalic birth. Many interviewees said that the position in which a pregnant woman sleeps could impact the fetal position. Several participants had either taken or heard of medication intended to rotate the fetus into the correct position. CONCLUSIONS: Our findings suggest the mixed quality of and access to care associated with non-cephalic birth and a lack of consistent understanding of the risk of and care for non-cephalic births in rural Nepal. The high risk of the condition and the recommended tertiary care present a dilemma in low-resource settings; the logistical difficulties and the mixed quality of care make care-seeking and referral decisions complex. While public health stakeholders strive to improve the quality of and access to the formal health system, those players must also be sensitive to the potential negative implications of promoting institutional care-seeking

Clean birth and postnatal care practices to reduce neonatal deaths from sepsis and tetanus: a systematic review and Delphi estimation of mortality effect

BACKGROUND: Annually over 520,000 newborns die from neonatal sepsis, and 60,000 more from tetanus. Estimates of the effect of clean birth and postnatal care practices are required for evidence-based program planning. OBJECTIVE: To review the evidence for clean birth and postnatal care practices and estimate the effect on neonatal mortality from sepsis and tetanus for the Lives Saved Tool (LiST). METHODS: We conducted a systematic review of multiple databases. Data were abstracted into standard tables and assessed by GRADE criteria. Where appropriate, meta-analyses were undertaken. For interventions with low quality evidence but a strong GRADE recommendation, a Delphi process was conducted. RESULTS: Low quality evidence supports a reduction in all-cause neonatal mortality (19% (95% c.i. 1-34%)), cord infection (30% (95% c.i. 20-39%)) and neonatal tetanus (49% (95% c.i. 35-62%)) with birth attendant handwashing. Very low quality evidence supports a reduction in neonatal tetanus mortality with a clean birth surface (93% (95% c.i. 77-100%)) and no relationship between a clean perineum and tetanus. Low quality evidence supports a reduction of neonatal tetanus with facility birth (68% (95% c.i. 47-88%). No relationship was found between birth place and cord infections or sepsis mortality. For postnatal clean practices, all-cause mortality is reduced with chlorhexidine cord applications in the first 24 hours of life (34% (95% c.i. 5-54%, moderate quality evidence) and antimicrobial cord applications (63% (95% c.i. 41-86%, low quality evidence). One study of postnatal maternal handwashing reported reductions in all-cause mortality (44% (95% c.i. 18-62%)) and cord infection ((24% (95% c.i. 5-40%)).Given the low quality of evidence, a Delphi expert opinion process was undertaken. Thirty experts reached consensus regarding reduction of neonatal sepsis deaths by clean birth practices at home (15% (IQR 10-20)) or in a facility (27% IQR 24-36)), and by clean postnatal care practices (40% (IQR 25-50)). The panel estimated that neonatal tetanus mortality was reduced by clean birth practices at home (30% (IQR(20-30)), or in a facility (38% (IQR 34-40)), and by clean postnatal care practices (40% (IQR 30-50)). CONCLUSION: According to expert opinion, clean birth and particularly postnatal care practices are effective in reducing neonatal mortality from sepsis and tetanus. Further research is required regarding optimal implementation strategies

Prevalence of small-for-gestational age and its mortality risk varies by choice of birth-weight-for-gestation reference population

Background We use data from rural Nepal and South India to compare the prevalence of small-for-gestational-age (SGA) and neonatal mortality risk associated with SGA using different birth-weight-for-gestation reference populations. Methods We identified 46 reference populations in low-, middle-, and high-income countries, of which 26 met the inclusion criteria of being commonly cited and having numeric 10th percentile cut points published. Those reference populations were then applied to populations from two community-based studies to determine SGA prevalence and its relative risk of neonatal mortality. Results The prevalence of SGA ranged from 10.5% to 72.5% in Nepal, and 12.0% to 78.4% in India, depending on the reference population. Females had higher rates of SGA than males using reference populations that were not sex specific. SGA prevalence was lowest when using reference populations from low-income countries. Infants who were both preterm and SGA had much higher mortality risk than those who were term and appropriate-for-gestational-age. Risk ratios for those who are both preterm and SGA ranged from 7.34–17.98 in Nepal and 5.29–11.98 in India, depending on the reference population. Conclusions These results demonstrate the value of a common birth-weight-for-gestation reference population that will facilitate comparisons of SGA prevalence and mortality risk across research studies

Seasonality of birth outcomes in rural Sarlahi District, Nepal: a population-based prospective cohort

Background While seasonality of birth outcomes has been documented in a variety of settings, data from rural South Asia are lacking. We report a descriptive study of the seasonality of prematurity, low birth weight, small for gestational age, neonatal deaths, and stillbirths in the plains of Nepal. Methods Using data collected prospectively during a randomized controlled trial of neonatal skin and umbilical cord cleansing with chlorhexidine, we analyzed a cohort of 23,662 babies born between September 2002 and January 2006. Project workers collected data on birth outcomes at the infant’s household. Supplemental data from other studies conducted at the same field site are presented to provide context. 95% confidence intervals were constructed around monthly estimates to examine statistical significance of findings. Results Month of birth was associated with higher risk for adverse outcomes (neonatal mortality, low birthweight, preterm, and small for gestational age), even when controlling for maternal characteristics. Infants had 87% (95% CI: 27 – 176%) increased risk of neonatal mortality when born in August, the high point, versus March, the low point. Conclusion Seasonality of neonatal deaths, stillbirths, birth weight, gestational age, and small for gestational age were found in Nepal. Maternal factors, meteorological conditions, infectious diseases, and nutritional status may be associated with these adverse birth outcomes. Further research is needed to understand the causal mechanisms that explain the seasonality of adverse birth outcomes