Mistreatment of newborns after childbirth in health facilities in Nepal: results from a prospective cohort observational study

Background: Patient experience of care reflects the quality of health care in health facilities. While there are multiple studies documenting abuse and disrespect to women during childbirth, there is limited evidence on the mistreatment of newborns immediately after childbirth. This paper addresses the evidence gap by assessing the prevalence and risk factors associated with mistreatment of newborns after childbirth in Nepal, based on a large-scale observational study. Methods and findings: This is a prospective observational cohort study conducted over a period of 18 months in 4 public referral hospitals in Nepal. All newborns born at the facilities during the study period, who breathed spontaneously and were observed, were included. A set of indicators to measure mistreatment for newborns was analysed. Principal component analysis was used to construct a single newborn mistreatment index. Uni-variate, multi-variate, and multi-level analysis was done to measure the association between the newborn mistreatment index and demographic, obstetric, and neonatal characteristics. A total of 31,804 births of newborns who spontaneously breathed were included. Among the included newborns, 63.0% (95% CI, 62.5-63.5) received medical interventions without taking consent from the parents, 25.0% (95% CI, 24.5-25.5) were not treated with kindness and respect (roughly handled), and 21.4% (95% CI, 20.9-21.8) of them were suctioned with no medical need. Among the newborns, 71.7% (95% CI, 71.2-72.3) had the cord clamped within 1 minute and 77.6% (95% CI, 77.1-78.1) were not breast fed within 1 hour of birth. Only 3.5% (95% CI, 3.2-3.8) were kept in skin to skin contact in the delivery room after birth. The mistreatment index showed maximum variation in mistreatment among those infants born to women of relatively disadvantaged ethnic groups and infants born to women with 2 or previous births. After adjusting for hospital heterogeneity, infants born to women aged 30-34 years (beta, -0.041; p value, 0.01) and infants born to women aged 35 years or more (beta, -0.064; p value, 0.029) were less mistreated in reference to infants born to women aged 18 years or less. Infants born to women from the relatively disadvantaged (chhetri) ethnic groups (beta, 0.077; p value, 0.000) were more likely to be mistreated than the infants born to relatively advantaged (brahmin) ethnic groups. Female newborns (beta, 0.016; p value, 0.015) were more likely to be mistreated than male newborns. Conclusions: The mistreatment of spontaneously breathing newborns is high in public hospitals in Nepal. Mistreatment varied by hospital, maternal ethnicity, maternal age, and sex of the newborn. Reducing mistreatment of newborns will require interventions at policy, health system, and individual level. Further, implementation studies will be required to identify effective interventions to reduce inequity and mistreatment of newborns at birth

Improving newborn care practices through home visits: lessons from Malawi, Nepal, Bangladesh, and Uganda.

Background: Nearly all newborn deaths occur in low- or middle-income countries. Many of these deaths could be prevented through promotion and provision of newborn care practices such as thermal care, early and exclusive breastfeeding, and hygienic cord care. Home visit programmes promoting these practices were piloted in Malawi, Nepal, Bangladesh, and Uganda. Objective: This study assessed changes in selected newborn care practices over time in pilot programme areas in four countries and evaluated whether women who received home visits during pregnancy were more likely to report use of three key practices. Design: Using data from cross-sectional surveys of women with live births at baseline and endline, the Pearson chi-squared test was used to assess changes over time. Generalised linear models were used to assess the relationship between the main independent variable – home visit from a community health worker (CHW) during pregnancy (0, 1–2, 3+) – and use of selected practices while controlling for antenatal care, place of delivery, and maternal age and education. Results: There were statistically significant improvements in practices, except applying nothing to the cord in Malawi and early initiation of breastfeeding in Bangladesh. In Malawi, Nepal, and Bangladesh, women who were visited by a CHW three or more times during pregnancy were more likely to report use of selected practices. Women who delivered in a facility were also more likely to report use of selected practices in Malawi, Nepal, and Uganda; association with place of birth was not examined in Bangladesh because only women who delivered outside a facility were asked about these practices. Conclusion: Home visits can play a role in improving practices in different settings. Multiple interactions are needed, so programmes need to investigate the most appropriate and efficient ways to reach families and promote newborn care practices. Meanwhile, programmes must take advantage of increasing facility delivery rates to ensure that all babies benefit from these practices

Scaling Up Safer Birth Bundle Through Quality Improvement in Nepal (SUSTAIN) - A stepped wedge cluster randomized controlled trial in public hospitals

Background: Each year, 2.2 million intrapartum-related deaths (intrapartum stillbirths and first day neonatal deaths) occur worldwide with 99% of them taking place in low- and middle-income countries. Despite the accelerated increase in the proportion of deliveries taking place in health facilities in these settings, the stillborn and neonatal mortality rates have not reduced proportionately. Poor quality of care in health facilities is attributed to two-thirds of these deaths. Improving quality of care during the intrapartum period needs investments in evidence-based interventions. We aim to evaluate the quality improvement packageScaling Up Safer Bundle Through Quality Improvement in Nepal (SUSTAIN)on intrapartum care and intrapartum-related mortality in public hospitals of Nepal. Methods: We will conduct a stepped wedge cluster randomized controlled trial in eight public hospitals with each having least 3000 deliveries a year. Each hospital will represent a cluster with an intervention transition period of 2months in each. With a level of significance of 95%, the statistical power of 90% and an intra-cluster correlation of 0.00015, a study period of 19months should detect at least a 15% change in intrapartum-related mortality. Quality improvement training, mentoring, systematic feedback, and a continuous improvement cycle will be instituted based on bottleneck analyses in each hospital. All concerned health workers will be trained on standard basic neonatal resuscitation and essential newborn care. Portable fetal heart monitors (Moyo (R)) and neonatal heart rate monitors (Neobeat (R)) will be introduced in the hospitals to identify fetal distress during labor and to improve neonatal resuscitation. Independent research teams will collect data in each hospital on intervention inputs, processes, and outcomes by reviewing records and carrying out observations and interviews. The dose-response effect will be evaluated through process evaluations. Discussion: With the global momentum to improve quality of intrapartum care, better understanding of QI package within a health facility context is important. The proposed package is based on experiences from a similar previous scale-up trial carried out in Nepal. The proposed evaluation will provide evidence on QI package and technology for implementation and scale up in similar settings

Feasibility of implementing public-private mix approach for tuberculosis case management in Pokhara Metropolitan City of western Nepal: a qualitative study

BackgroundThe Public-Private Mix (PPM) approach is a strategic initiative that involves engaging all private and public health care providers in the fight against tuberculosis using international health care standards. For tuberculosis control in Nepal, the PPM approach could be a milestone. This study aimed to explore the barriers to a public-private mix approach in the management of tuberculosis cases in Nepal.MethodsWe conducted key informant interviews with 20 participants, 14 of whom were from private clinics, polyclinics, and hospitals where the PPM approach was used, two from government hospitals, and four from policymakers. All data were audio-recorded, transcribed, and translated into English. The transcripts of the interviews were manually organized, and themes were generated and categorized into 1. TB case detection, 2. patient-related barriers, and 3. health-system-related barriers.ResultsA total of 20 respondents participated in the study. Barriers to PPM were identified into following three themes: (1) Obstacles related to TB case detection, (2) Obstacles related to patients, and (3) Obstacles related to health-care system. PPM implementation was challenged by following sub-themes that included staff turnover, low private sector participation in workshops, a lack of trainings, poor recording and reporting, insufficient joint monitoring and supervision, poor financial benefit, lack of coordination and collaboration, and non-supportive TB-related policies and strategies.ConclusionGovernment stakeholders can significantly benefit by applying a proactive role working with the private in monitoring and supervision. The joint efforts with private sector can then enable all stakeholders to follow the government policy, practice and protocols in case finding, holding and other preventive approaches. Future research are essential in exploring how PPM could be optimized

Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19

IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non–critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support–free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570

Evaluation of Ginger Oleoresin in Carbon Tetrachloride Induced Hepatotoxicity in Rats

The present study evaluated the hepatoprotective activity of ginger oleoresin against Carbontetrachloride induced liver toxic damage in rats. Rats were divided into six groups. Hepatotoxicity was induced by the administration of a single intraperitoneal dose (2ml/kg) of Carbontetrachloride in experimental rats. Post-treatment with Ginger oleoresin at 300 and 600mg/kg dose given by oral routewas carried out to find their protective effectsagainst carbontetrachloride induced hepatic injury. Biochemical parameterfor oxidative stress, inflammation and lipid profile along with genotoxicity and histological changes in rat serum and liver were studied. Silymarin was used as standard hepatoprotective agent. Extracted oleoresin dose dependently provided hepatoprotective effects.The hepatoprotective action of ginger oleoresin may be related to its free radical scavenging,anti-inflammatory and hypolipidemic activity and concluded to be partly mediated by its active constituent’s 6-gingerol, shogaol and zingerone. -phospate; CCl3 *, Trichloromethyl free radical; CCl3 OO*, Trichloromethyl peroxy radical; ROS, Reactive oxygen species; iNOS, inducible nitric oxide synthase; NO, Nitric oxide, VLDL, Very low density lipoprotein

Efficacy of Biorational Compounds against Mustard Aphid (Lipaphis erysimi Kalt.) and English Grain Aphid (Sitobion avenae Fab.) under Laboratory Conditions in Nepal

Mustard aphid (Lipaphis erysimi) and English grain aphid (Sitobion avenae) are among the most important pests in mustard and wheat fields in Nepal. Biocide Manic (Metarhizium anisopliae a.i. = 1 × 109 spores/ml) at 3 ml/l water, Agri Sakti (Beauveria bassiana a.i. = 1 × 109 spores/ml) at 3.3 ml/l water, Varunastra (Verticillium lecanii spores 2% aqueous suspension, 2 × 108 CFU/ml) at 6 ml/l water, Mahastra (Bacillus thuringiensis var. kurstaki 0.5% wettable powder) at 6 g/l water, Neemraj Super (Azadirachitin 0.3% w/w) at 3.3 ml/l water, Tracer (Spinosad 90% spinosyns) at 0.33 ml/l water, and control treatment (pure water) were used to test their efficacy against L. erysimi and S. avenae, using leaf dip and spray methods under laboratory conditions in Rupandehi, Nepal, in the year 2018. Each treatment was replicated four times, and the experiment was carried out in a randomized complete block design. Mortality of aphids was recorded at 24, 48, 72, and 98 hours after treatment application. The result revealed highest mortality of mustard aphids with Agri Sakti at 24 hours after treatment (HAT); however, Neemraj Super was found to be the most effective at 48, 72, and 96 HAT with the leaf spray method. With the leaf dip method, Neemraj Super killed more mustard aphids than other treatments at all observed time points. Among tested biorational products, Agri Sakti was found to be most effective against English grain aphids in both leaf spray and leaf dip methods. In all the bioassays, the mortality caused by biorational compounds over control was highly significant. The present study suggests for further verification of the biorational products in the field and development of novel management strategies against different species of aphids

Lessons from Managing for the Extremes: A Case for Decentralized, Adaptive, Multipurpose Forest Management within an Ecological Framework

Multipurpose and ecological forest management frameworks are being increasingly applied across the Global North on public lands. However, the discourse and practice of public forest management in much of the developing world are captured by extreme approaches of single-crop (usually timber) production and strict canopy-cover protection, as exemplified by the case of Nepal. We combine insights from field research with published documents and trace the consequences of prevalent management regimes on the ecology and silviculture of Nepal’s public forests. We find that managing for either extreme of timber production or forest protection can degrade forest ecosystems and affect their capacity to address the increasing number of demands placed on them. A history of narrow management outlooks has erased indigenous silvicultural practices and discouraged the development of novel silvicultural solutions to address today’s environmental concerns. Government initiatives advancing singular objectives, such as Nepal’s Scientific Forest Management program, often crumble under political resistance. Forest users in Nepal are widely interested in generating diverse benefits from their forests, including non-commercial products and services, suggesting a mandate for multipurpose management. We present a decentralized adaptive modality of multipurpose management featuring a silviculture that more closely matches the ecology of forests

Comparative Study of Corrosion Inhibition Efficacy of Alkaloid Extract of Artemesia vulgaris and Solanum tuberosum in Mild Steel Samples in 1 M Sulphuric Acid

Two different types of alkaloids are successfully extracted from two plants Artemisia vulgaris (AV) and Solanum tuberosum (ST) in the laboratory and used as corrosion inhibitors for mild steel samples. The corrosion inhibition potential of these alkaloids is determined by weight loss and potentiodynamic polarization measurement methods. Based on the weight loss measurement study of a sample immersed for 6 h in 1000 ppm inhibitor solution of AV and ST alkaloids, the corrosion inhibition efficiency is found to be 92.58% and 90.79%, respectively. The potentiodynamic polarization measurement shows 88.06% and 83.22% corrosion inhibition efficiency for AV and ST alkaloids, respectively, for the sample immersed for 1 h in 1000 ppm inhibitor solution. These promising efficiency and suitable immersion time effect can lead to the development of good green inhibitors