भ्रूण हत्याले छोराको संख्या बढ्यो, छोरी कम हुँदैं :: Cross sectional, community based study of care of newborn infants in Nepal
"Results: 4893 (90%) women gave birth at home. Attendance at delivery by skilled government health workers was low (334, 6%), as was attendance by traditional birth attendants (267, 5%). Only 461 (8%) women had used a clean home delivery kit, and about half of attendants had washed their hands. Only 3482 (64%) newborn infants had been wrapped within half an hour of birth, and 4992 (92%) had been bathed within the first hour. 99% (5362) of babies were breast fed, 91% (4939) within six hours of birth. Practices with respect to colostrum and prelacteals were not a cause for anxiety.
Conclusions: Health promotion interventions most likely to improve newborn health in this setting include increasing attendance at delivery by skilled service providers, improving information for families about basic perinatal care, promotion of clean delivery practices, early cord cutting and wrapping of the baby, and avoidance of early bathing."
छोरा र छोरी बिचको यो अन्तर हाल आएर असामान्य बन्दै गएको छ । ब्रिटिस मेडिकल जर्नल (बीएमजे)ले सन् २०१३ मा नेपालमा गरेको एक अध्ययन अनुसार एक हजार छोरा जन्मँदा ७ सय ४२ मात्र छोरी जन्मिएको पाइएको हो । पहिलो सन्तान छोरी भएकाले दोश्रो सन्तान जन्माउँदाको अवस्थालाई अनुसन्धान गर्दा यस्तो पाइएको बीएमजेले जनाएको कान्तिपुर दैनिकमा खबर छ ।
शहरी क्षेत्रमा रहेका शिक्षित महिलाले छोरी भन्दा बढी छोरा जन्माएको देखिएको छ । काठमाडौं, ललितपुर र भक्तपुरका अस्पतालहरुको अनुसन्धान गर्दा एक हजार छोरा जन्मदा ३ सय २६ मात्र छोरी जन्मिएको पाइएको हो । ‘शहरी क्षेत्रमा छोरा र छोरी बिचको अन्तर घट्दै जानु अत्यन्तै चिन्ताको विषय हो’ प्रजनन स्वास्थ्य विज्ञ अरुणा उप्रेतीले भनिन्, ‘यसबाट चेतनाको स्तर उठेका र शिक्षत महिला नै छोरा जन्माउन चाहेको देखिन्छ ।’ तर, राज्यले यसबारेमा अझै केही सोच्न नसकेको उनले जानकारी दिइन् ।
उनका अनुसार पछिल्लो समय भ्रुणको लिङ्ग पहिचान गरी छोरी भए गर्भपतन गराउने भएकाले छोरा बढी जन्मिएका हुन् । गर्भपतनले कानुनी मान्यता पाएपछि र नेपालमै भ्रुणको लिङ्ग पहिचान गर्न सकिने प्रविधिहरु भित्रिएपछि यस्तो देखिएको हो । नेपालमा सुरक्षित गर्भपतनले मान्यता नपाएको अवस्थामा पनि मानिसहरु भारत गएर भ्रुणको लिङ्ग पहिचान गरी गर्भपतन गराउने गर्थे । त्यतिबेला थोरै महिलाको मात्रै त्यहाँ सम्म पुग्ने पहुँच हुन्थ्यो । अहिले नेपालको गाउँ/गाउँमा सुरक्षित गर्भपतन सेवा पुगेको छ ।
कानुन बमोजिम १२ हप्तासम्मको भ्रुणलाई मात्र गर्भपतन गराउन सकिन्छ । तर, भ्रुणको लिङ्ग पहिचान गरेर गर्भपतन गराउन पाइदैन । भु्रणको लिङ्ग पहिचान गरी गर्भपतन गराउने चिकित्सक र महिला दुबैलाई कारवाही गरिने कानुनी व्यवस्था छ । ‘यति हुँदा हुँदै परिवार र समाजबाट छोरा जन्माउनकै लागि दिइने दबाब र मानसिक यातनाले गर्दा महिला आफै छोरा जन्माउन चाहान्छन्,’ डाक्टर उप्रेतीले भनिन्, ‘यसलाई नबुझेर कतिपयले ‘भ्रुण हत्या’ लेख्ने र भन्ने गरेका छन् । हत्या शब्दको प्रयोगले महिलाले पाइसकेको गर्भपतनको अधिकारमाथि नै प्रश्न उठ्न थालेकाले यसलाई भ्रुणको लिङ्ग पहिचान गरी गर्भपतन भन्न सबैलाई आग्रह गर्दछु ।’
गर्भपतनलाई कानुनी मान्यता दिनुभन्दा पहिला सन् १९९८ देखि २००० सम्मको तथ्याङ्कलाई हेर्दा नेपालमा एक हजार छोरा जन्मदा १ हजार २१ छोरी जन्मने गरेका थिए । सन् २००२ मा गर्भपतनले कानुनी मान्यता पाएपछि छोरी जन्मने संख्या घट्दै गएको हो ।
Original Report by them
Abstract
Objective: To determine home based newborn care practices in rural Nepal in order to inform strategies to improve neonatal outcome.
Design: Cross sectional, retrospective study using structured interviews.
Setting: Makwanpur district, Nepal.
Participants: 5411 married women aged 15 to 49 years who had given birth to a live baby in the past year.
Main outcome measures: Attendance at delivery, hygiene, thermal care, and early feeding practices.
Results: 4893 (90%) women gave birth at home. Attendance at delivery by skilled government health workers was low (334, 6%), as was attendance by traditional birth attendants (267, 5%). Only 461 (8%) women had used a clean home delivery kit, and about half of attendants had washed their hands. Only 3482 (64%) newborn infants had been wrapped within half an hour of birth, and 4992 (92%) had been bathed within the first hour. 99% (5362) of babies were breast fed, 91% (4939) within six hours of birth. Practices with respect to colostrum and prelacteals were not a cause for anxiety.
Conclusions: Health promotion interventions most likely to improve newborn health in this setting include increasing attendance at delivery by skilled service providers, improving information for families about basic perinatal care, promotion of clean delivery practices, early cord cutting and wrapping of the baby, and avoidance of early bathing.
What is already known on this topic
What is already known on this topic Most births in rural south Asia occur at home
Neonatal mortality has remained fairly constant in developing countries despite falling infant mortality
What this paper adds
What this paper adds Only 6% of births in rural Nepal took place in the presence of a skilled attendant
Cord cutting implements were often unclean and drying and wrapping of newborn infants was usually delayed
99% of babies were breast fed, 92% of them within six hours of birth, and colostrum was generally given
Interventions need to focus on educating women about hygiene, encouraging early wrapping, and delaying bathing of newborn babies
Introduction
Although infant mortality has fallen in many developing countries over the past two decades, the rate of fall may be slowing.1 One reason is the resistant contribution of neonatal mortality, which has remained fairly steady over this period. 2 3 For many mothers, health care during and after childbirth is virtually non-existent, and in 2000, an estimated 53 million women in developing countries gave birth without professional help.4
The World Health Organization guidelines for essential newborn care encompass cleanliness, thermal protection, initiation of breathing, early and exclusive breast feeding, eye care, immunisation, management of illness, and the care of low birthweight infants.5 For a mother and her family, this means preparing for birth, choosing a safe place for delivery, keeping the process clean, avoiding the cold, breast feeding early and exclusively, and understanding (and reacting to) potential danger signs. Our understanding of what happens at home and how to change behaviour is limited.
We are conducting a cluster randomised controlled trial on the effect of a community based participatory intervention to improve essential newborn care in Nepal. The trial involves 170 000 rural people in 12 pairs of village development committees in Makwanpur district. The aim of the present study was to describe newborn care practices quantitatively in the cohort of women recruited to the trial.
Participants and methods
Setting
Nepal has a population of 23.4 million with more than 60 ethnic groups. The landscape tiers down from the Himalayas, through middle hills, to plains in the south.6 The population is poor, and there are limited communications and infrastructure. The gross national product per head is about $220 (£145, €223),7 the human development index is 0.378,8 life expectancy is 58 years, about 60% of adults are illiterate,7 the total fertility rate is 4.8 in rural areas, and early marriage and adolescent pregnancy are common.9
Nepal's estimated neonatal mortality rate is 50/1000 live births and accounts for two thirds of the infant mortality rate (79/1000).9 Less than half of pregnant women attend for any antenatal care,9–13 and over 90% of births occur at home.9 After marriage, women usually move into their husband's family home and their mother-in-law becomes the central female figures in their lives. They give birth at home in the company of female friends and family, and their mother-in-law often takes the lead in advising on birth, childcare, illness, and when and where to seek professional help.
Nepal introduced integrated primary health care in the late 1970s, with tertiary hospitals at the centre, zonal and district hospitals in the periphery, and a hierarchy of primary health centres, health posts, and subhealth posts in the community. The system suffers from unfilled posts, absenteeism, shortfalls in equipment and drugs, limited support to community based staff, and a lack of refresher training.14
Makwanpur district
Makwanpur district lies to the south of Kathmandu and has a population of nearly 400 000. It covers an area of 2500 km2 and includes both hills and plains. Over much of the district access is difficult and villages are widely spread. Most residents are engaged in small scale agriculture. There are at least 15 ethnic groups, the largest of which is Tamang (a predominantly Buddhist, Tibeto-Burman group), followed by Brahmin and Chhetri (groups of Indo-Aryan origin).
The district is geopolitically divided into 43 village development committees. Each committee has one government health institution (subhealth post, health post, or primary health centre). Perinatal care is provided from these facilities and the district hospital as well as by traditional birth attendants. Both service provision and uptake are patchy.
Study design
We conducted a cross sectional, descriptive study to collect information about most recent deliveries for women in Nepal. Married women of reproductive age (between 15 and 49 completed years on 15 June 2000) were eligible to enter a closed cohort. Chairs of the village development committees provided signed consent and all participants provided verbal consent to involvement. The study received ethical clearance from the Nepal Health Research Council, from His Majesty's Government Ministry of Health, Nepal, and from the ethics committee of the Institute of Child Health and Great Ormond Street Hospital for Sick Children, London.
We identified and mapped 28 376 households between September 1999 and June 2000. Each married woman of reproductive age was allocated a unique identification number and visited by the field team to complete an individual questionnaire, including questions about newborn care during any preceding birth. The questionnaire was developed over 18 months through 11 cycles of piloting, evaluation, and repeat piloting. Data were collected by 44 field interviewers between March and November 2001, supported by nine field coordinators and one senior officer. Questionnaires were checked and missed questions amended at source, at field centres, and at the central office. A tenth of interviews were observed by supervisory team members.
We entered data into a relational database management system in Microsoft SQL server 7.0, which also incorporated intrafield and interfield constraints. We examined frequencies and outliers through structured queries in the database environment. We also analysed proportions after exporting data to small Stata 5.0. We have rounded percentages to integers for presentation.
Results
We interviewed 25 702 women, of whom 24 295 had given birth at least once, 24 244 to a live baby. Because of concerns about the validity of recall over longer periods and the likelihood that practices have changed over time, we limited our analysis to the 5411 live births within the year before the start of the study. The median age of respondents was 25.1 years (interquartile range 9.3 years).
Skilled attendance at delivery
In all, 4893 (90%) of women gave birth at home, either inside or in the courtyard (table 1). The district hospital accounted for 251 (5%) births. Six hundred and nineteen (11%) women gave birth alone. When an attendant was present, she was usually a family member or neighbour (4241, 78%), particularly the woman's mother-in-law (2178, 40%).
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