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Rapid Responses: Rapid Responses published:
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Health Education for Nepali women
- Susheel Oommen John (8 November 2002)
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Empower women in All Spheres
- Paras Kumar Pokharel, BP Koirala Institute of health Sciences,Dharan,Nepal (9 November 2002)
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Valuable Survey
- Ian A Baker (15 November 2002)
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Skilled attendant or skilled attendance?
- Andrew S Furber (21 November 2002)
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A community-based intervention: a cost-effective means of improving newborn care in rural Nepal?
- Josephine Borghi, Bidur Thapa, Mother and Infant Research Activities, GPO Box 921, Kathmandu, Nepal (27 November 2002)
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Exporting Bad Practices to Nepal
- Cory A. Mermer (9 January 2003)
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Justification for the research in the district
- Ananta Niraula (10 September 2008)
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Susheel Oommen John, Resident , Internal Medicine Christian Medical College, Ludhiana, India 141008
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The cross sectional study by David Osrin et al is impressive, although my personal observations during a two year period at a secondary level hospital in Lalitpur district, Nepal was that most pregnant women who had access to health care facilities had regular Antenatal visits, had regular immunisations against tetanus and received Iron suppliments on a regular basis and those who could afford had hospital delivery.
What was more intersting was that the babies born at home were brought for immunisation as soon as within 24-48 hours, and had all other immunisations regularly as per schedule.Yet another interseting feature was that these women were well informed about family planning methods and often opted for and regularly continued the use of Depo Provera which was available free of cost through the Ministry of Health , HMG. The probable reasons for such a high home delivery rate in Nepal is the lack of easily accessible health services and inability to afford the hospitalisation related costs more than just lack of health education. How can they be educated on these issues if they dont have the access to it? Susheel John Competing interests: None declared |
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Paras Kumar Pokharel, Associate Professor Department of Community Medicine, BP Koirala Institute of health Sciences,Dharan,Nepal
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Dear Author We are working relatively remote region than your study area.The scenario is not the same,Female Child Health Volunteers who is Pillar of Rural Health Care in Nepal are in every village in population of one to two hundred households.They are the source of changes and our interactions with them made us to think women of Nepal need opportunities to earn,sustain and make dicisions in realtion to their Children.Micro Credit,Opportunities in Jobs,Professional Educations,Facilities in Catchment areas to utilize services in time; may change present stataus.In the Country where 90% trained Pediatricians provide services to 10% of Children.80%Doctors are in Kathmandu vally to serve 1.5 Million Population leaving 21.5 million in the mercy of Lord Pashupati Nath,your ideas about Health Education is good.But Nepali women do understand the real issues,you will find Wrapping Child immidiately after birth is healthy traditional Practices in Rural Nepal.Delivery Kit is not accessable in place they live so they use new Blades to cut Cord.Good immunization Coverage with coordination of FCHV and Health workers in villages. Neonatal tetanus is rear now a days compare to past.I remember in one occassion to a new born mother Intern were asking to give breast milk exclusively,She replied what other way Mother can think if not breast feeding.This is the a GOD's gift and biggest satisfaction to feel Mother.Intern looked upon all around.I am really convinced with Colleaugue from Vellore who would have worked in Patan,but Tansen or Tekankpur Okahldhunga Mission Hospital experiences may not differ from his one, though it is very remote than many can imagine.Solution is not to say what do,Intervention is needed to demonstrate how one can do in simillar situation other than what they are doing. Competing interests: None declared |
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Ian A Baker, Chair, The Britain Nepal Medical Trust 26 Broadway Road, Bristol BS7 8ES
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David Osrin and his team are to be congratulated onthis cross- sectional survey, which has been well-conducted and analysed. Such surveys in any location in Nepal are not easy. Staff in The Britain Nepal Medical Trust conducted a smaller baseline survey in Khotang District in the mid-hills of the Eastern Region in 2000. From women of reproductive ages in 278 households; 60% had first pregnancies before the age of 20 years 72% had no ante natal checks 70% of deliveries were attended by untrained persons 23% of deliveries had no support 71% of deliveries took place in unclean settings The Trust is about to embark on participatory approaches with partners, including Goverment services, and local communities, to seek plans and innovations towards simple interventions to reduce maternity risks. It would be helpful to learn if the questionnaire used by Osrin is available for others to use in baseline and follow-up surveys? Also to know of what background were the interviewers,the length of training for interviewers, and the length of time for administration of the questionnaire? Ian Baker Competing interests: None declared |
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Andrew S Furber, SpR Public Health (formerly HIV Consultant, Nepal) Eastern Wakefield PCT, Castleford, WF10 5LT
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Editor – Osrin et al (1) are to be congratulated for completing an important study in a district that is experiencing significant levels of disruption and violence due to Nepal’s Maoist insurgency. Despite working for a number of years in a similar rural district in Nepal, the level of care available to women and their newborn babies documented in their study remains shocking, if not surprising. Two issues raised in the paper merit further comment. Firstly, it would be unwise to be complacent on the current high levels of breastfeeding. As the authors will be aware, dried formula milk is now widely available in rural areas. In my experience, female health workers often use formula milk themselves in the misguided belief that they can safely supplement or replace their own breast milk (sometimes from the need to return to work quickly after maternity leave). Such practice from people who should be role models is deeply worrying. Secondly, it is hard to know how to provide an attendant of a sufficient level of skill at every delivery when most Nepalese live in hard to access rural areas. Even if this were possible, referral to centres where emergency obstetric care and neonatal facilities are available is fraught with difficulties (2). It may be preferable for women to attend a place where this level of care can be provided, although this policy also has its limitations. Whichever route is taken, it is clear that the current political instability in Nepal makes delivering effective health care in rural areas even more of a challenge. References 1. Osrin D, Tumbahangphe KM, Shrestha D, et al. Cross sectional, community based study of care of newborn infants in Nepal. BMJ 2002;325:1063-6. 2. Furber AS. Referral to hospital in Nepal: four years’ experience in one rural district. Tropical Doctor 2002;32:75-78(April). Competing interests: None declared |
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Josephine Borghi, Research Fellow London School of Hygiene & Tropical Medicine, WC1E 7HT, Institute of Child Health, WCIN 1EH, Bidur Thapa, Mother and Infant Research Activities, GPO Box 921, Kathmandu, Nepal
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EDITOR - Osrin et al.1 conclude that interventions to improve neonatal health in rural Nepal could focus on educating mothers-in-law, pregnant women and other family members about hygiene, encouraging early wrapping and delaying bathing of newborn babies. They are currently evaluating the effectiveness of this approach through a cluster randomised controlled trial of a community-based participatory intervention. In the face of the scarcity of health care resources, decision-makers also need evidence of an intervention’s cost-effectiveness compared to alternative investments, so an economic evaluation is being carried out alongside the trial. Our experience so far confirms the difficulty of adapting the conventional tools of economic analysis, in terms of benefit and cost measurement, to the evaluation of this type of intervention as illustrated in the health promotion2 and social welfare3 literature. Defining the scope of the intervention and the appropriate timeframe for evaluation present obstacles that are magnified by the socio-economic and geographical characteristics of the setting. Health economists often consider that there is no benefit from the consumption of health care other than the derived benefit from health5 and the most common form of economic evaluation in the health sector, cost-effectiveness analysis, usually compares the resource costs of an intervention to reductions in morbidity and/or mortality. However, a community-based intervention is potentially more ‘holistic’ than clinical therapy, affecting cognitive, social, psychological as well as physical well-being, with possible ‘social diffusion’ effects4. The participatory nature of this intervention also means that community attitudes, behaviour and circumstances will affect outcomes. Furthermore, it is possible that significant changes in health will not be observed within the timeframe of a trial, even though behaviour change may have occurred and be valued by the community. Therefore, to avoid the risk of underestimating the intervention’s cost-effectiveness it is important to capture the value of education and knowledge of risk factors and their associations, which generate self- esteem and satisfaction as well as any social ‘process’ serving to improve networks between individuals. The valuation of community time spent participating in the programme presents an additional challenge, especially for women who are devoted to unpaid household production of non-market goods and services. Their contribution to full household income is likely to be substantial, yet methods for valuing foregone time for these activities are lacking. Health economics should develop new methods for tackling these issues in order to more accurately estimate the cost-effectiveness of this and other community-based intervention’s in the future. References 1 Osrin D, Tumbahangphe KM, Shrestha D, Mesko N, Shrestha BP, Manandhar MK, Standing H, Manandhar DS & Costello AM (2002) Cross sectional community based study of care of newborn infants in Nepal. British Medical Journal 325: 1063-6. 2 Cribb A & Haycox A (1989) Economic analysis in the evaluation of health promotion. Community Medicine 11(4): 299-305. 3 Sefton T, Byford S, McDaid D, Hills J & Knapp M (2002). Making the Most of It: Economic Evaluation in the Social Welfare Field. Joseph Rowntree Foundation. 4 Jan S (1998) A holistic approach to the economic evaluation of health programs using institutionalist methodology. Social Science & Medicine 47(10): 1565-1572. 5 Grossman M (1972) The Demand for Health: A Theoretical and Empirical Investigation. Columbia University Press for the National Bureau for Economic Research, New York. Competing interests: None declared |
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Cory A. Mermer, Independent Medical Researcher/Writer USA - Westfield, NJ 07090
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Editors, The paper by Osrin et al (1) is much more than a "study of care" of newborn infants in Nepal as the title states. It is in fact making recommendations about what the authors feel is the correct "standard of care". The problem however, is that their recommendation regarding early cord clamping is a very dangerous and ill-conceived one. Their recommendation for“early cord cutting” is simply a really bad idea in ANY culture, but this is even more so in an area of the world such as Nepal. The dangers of early cord clamping have been well documented (2, 3, and also see http://www.cordclamping.com for many other papers). Unfortunately, the practice continues unabated, despite all warnings to the contrary, even dating back more than 200 years (4). What makes matters even worse in Nepal, home of the Himalayas, are the high altitudes at which most of the population lives. Every breath taken by a baby in Nepal contains significantly less oxygen than a baby born at sea level (approximately half as much, depending on location). As a result, the oxygen saturation levels of hemoglobin in the blood of people living at high altitudes are significantly lower as well. As an example, the average 4-month old infant at sea level has an oxygen saturation level around 98%. Yet in the mountains of Tibet, the average varies from only 76% for ethnic Han Chinese up to 86% for native Tibetans, both well below their sea level counterparts (5). Since the high altitudes of Nepal are similar to those of Tibet, and the majority of the population of Nepal are either ethnic Sherpas who came to Nepal from Tibet 400-500 years ago or ethnic Tibetans, it is reasonable to assume that they also have similar oxygen saturation levels to those found in Tibet. According to a recent report on human adaptation to high altitudes (5): “In the womb, a fetus is buffered from the outside world by its mother. But once born, a mountain baby must cope with the rarefied atmosphere for itself. The first hurdle is to start breathing.” Well, this “first hurdle” just got a heck of a lot higher if Osrin’s “early cord cutting” recommendation is followed. And worse yet, the ramifications of not clearing that “hurdle” immediately at birth just got much worse as well. With the cord left intact, most babies will have at least a few minutes of a continued supply of oxygenated placental blood to keep them going until the lungs are fully functional. Babies who have their still- functioning placenta essentially amputated, not only must start breathing immediately, but must do so with breaths that contain about half the oxygen of a baby at sea level. And then, of course, remember that they must then adequately distribute this oxygen throughout the body with 25% to 50% less blood than nature intended for them to have. The report also states (5): “…in a fetus the pulmonary artery, which carries blood from the heart to the lungs, has a thick muscle wall but that this normally thins after birth when a baby starts breathing air. When native lowlanders live at high altitude their pulmonary artery reverts to the fetal structure, raising the blood pressure within it. But not Tibetans - their arterial walls remain thinner, so their pulmonary artery pressure is low. With less arterial resistance their hearts can pump larger quantities of blood to the lungs during exercise.” With the pulmonary arterial pressure of native highlanders, like the people of Nepal, already being especially low, the effects of the significant hypovolemia (low blood volume) caused by premature cord clamping will be even more pronounced, with blood pressure falling even lower (6) Low blood pressure, coupled with low blood volume and low blood oxygenation levels can only spell trouble. And the bad news doesn’t end there either. The 25% to 50% decrease in blood volume also means a similar decrease in iron stores. This will greatly increase the already extremely high risk of iron deficiency anemia. As a matter of fact, the United Nations estimates that iron deficiency is the world’s biggest health problem, affecting about 3.5 billion people – over half the world’s population – causing both mental and physical impairment. Yet allowing a simple placental transfusion to take place at birth, enough iron can be transferred to the newborn to usually prevent anemia throughout the first year of life (7)! A more recent study found that a nearly 8-fold greater risk of anemia at 3 months with immediate clamping (8). Of course, humans have adapted to the stresses caused by living at such high altitudes, over the course of many years and in a variety of ways. But such adaptation has NEVER in its history encountered the intentional interruption of a full physiological placental transfusion at birth. Yet this is EXACTLY what Osrin et al are recommending. What makes the matter all the more tragic is that current umbilical cord care practices in Nepal are currently so good, allowing normal physiology to take place, with the cord not normally being interfered with until the placenta is delivered (9). Rather than advising them to do otherwise, Obstetricians and Neonatologists of the West should follow their lead and stop interfering with normal physiology. In conclusion, the ramifications of immediate cord clamping on the people of Nepal will be great. Babies who are hypoxic, hypovolemic, hypotense, and anemic do not have very good prospects. Nepal may be a very rural area, with academics a much smaller part of life than most areas of the West, but do they really want brain damaged babies? Is the Nepalese school system prepared for all the “special education” classes that may be required for these children? Is the healthcare system prepared for the upsurge in cerebral palsy (10), respiratory distress syndrome (7, 11, 12), autism (13), renal dysfunction (6) and other problems that will result? And if these problems do come about, is Osrin et al, and the modern obstetrical field of which he is a product, willing to accept responsibility for them? REFERENCES: 1. Osrin D, Tumbahangphe KM, Shrestha D, Mesko N, Shrestha BP, Manandhar MK, Standing H, Manandhar DS, Costello AM. Cross sectional, community based study of care of newborn infants in Nepal. BMJ 2002 Nov 9;325(7372):1063. (see http://bmj.com/cgi/content/full/325/7372/1063 ) 2. Mercer JS. Current best evidence: a review of the literature on umbilical cord clamping. J Midwifery Womens Health 2001 Nov-Dec;46(6):402 -14 (see http://cordclamping.com/mercer%20review.pdf ) 3. Morley G. The Physiology and Iatrogenic Pathology of the Third Stage of Labor. Published online 2002 (see http://cordclamping.com/ErasmusDarwin.htm ) 4. Darwin E. Zoonomia 1801 3: 302. 5. Cohen D. Humans with altitude. New Scientist vol 176 issue 2367 - 02 November 2002, page 36. 6. Kunzel W. [Cord clamping at birth - considerations for choosing the right time (author's transl)] Z Geburtshilfe Perinatol 1982 Apr- May;186(2):59-64. 7. Linderkamp O. Placental transfusion: determinants and effects. Clinics in Perinatology 1982;9:559-592. 8. Gupta R, Ramji S. Effect of delayed cord clamping on iron stores in infants born to anemic mothers: a randomized controlled trial. Indian Pediatr 2002 Feb;39(2):130-5. (see http://www.indianpediatrics.net/feb2002/feb-130-135.htm for full-text) 9. Tamang S, Mesko N, Shrestha B, Osrin D, Manandhar M, Standing H, et al. A qualitative description of perinatal care practices in Makwanpur district, Nepal. Contrib Nepalese Stud 2001; 28: 10-19. 10. Myers RE. Two patterns of perinatal brain damage and their conditions of occurrence. American Journal of Obstetrics and Gynecology 1972; 112:246-276. 11. Peltonen T. Placental Transfusion, Advantage - Disadvantage. Eur J Pediatr. 1981;137:141-146. 12. Spears RL, Anderson GV, Brotman S, Farrier J, Kwan J, Masto A, Perrin L, Stebbins R. The effect of early versus late cord clamping on signs of respiratory distress. Am J Obstet Gynecol 1966 Jun 15;95(4):564- 8. 13. Simon N and Morley GM. Brainstem Lesions in Autism: Birth Asphyxia and Ischemia as Causative Factors. Presented at IMFAR conference Orlando, Florida, November 1, 2002 (see http://www.cordclamping.com/IMFAR/IMFARpaper.htm ) Competing interests: None declared |
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Ananta Niraula, MPH (student) Quest Diagnostics Inc. USA
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There are 75 districts in Nepal. According to WHO, there are other districts which have high infant mortality rate. Sample used in the research is not the representative sample. Why Makwanpur district was selected for research site is unknown. That is, what was the researchers’ justification to conduct the research in the district is unknown. What are WHO’s specific guidelines(if there are any) for newborn care in Nepal are unknown. The article has used the general guidelines instead. The article does not mention Nepal’s guidelines (if there are any) for newborn care, and how the practices in Makwanpur district were deviated from the standard. However, the article has successfully revealed the newborn care practices in the district. Competing interests: None declared |
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