<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114101136/63720cbc9c7e80680e0b7884jpeg.jpg" alt="" width="720" height="540"/><figcaption>Nurses Puspa Pandhak and Sumnima Khapung delivering the baby inside a jeep late at night on 3 March, after concluding that they could not reach the Tehrathum district hospital in time because of the bad road. Photo: DINESH BHATTARAI</figcaption></figure>Puspa Pandhak was just finishing her duty at a rural hospital in Tehrathum district last week when a 19-year-old woman was brought in on a stretcher, writhing in pain.As a birth attendant nurse, Pandhak had performed more than 100 safe deliveries in the past five years, but this maternity case was the first breech she was having to deal with.“As soon as I saw the position of the baby, we decided not to take the risk and take her to Tehrathum Hospital,” Pandhak says.Read also: <a href="https://www.nepalitimes.com/here-now/birth-and-death-during-a-pandemic/" target="_blank" rel="noopener noreferrer">Birth and death during a pandemic</a>, Nunuta RaiBut, as is often the case in rural Nepal, they could not get an ambulance. The condition of the mother and baby was deteriorating, and every second counted.Luckily, a four-wheel drive jeep just happened to pass by and gave them a lift. Pandhak and fellow nurse Sumnima Khapung got on with their patient, taking along their delivery kits.The road was bumpy and dangerous, made worse by the previous day’s heavy rain and the pitch black night. It was already 9:30PM, and they were nowhere near their destination.“It was a rough ride, and we were being thrown about inside the car, but I tried to reassure the young expecting mother since this would be her first baby,” Pandhak recalls.Read also: <a href="https://www.nepalitimes.com/here-now/who-will-save-nepals-poor-new-mothers/" target="_blank" rel="noopener noreferrer">Who will save Nepal's poor new mothers</a>, Rojita AdhikariIn the front seat, the patient’s mother and husband were panicking, and that was not helping at all. Then driver Dinesh Bhattarai also started getting unnerved, and that was not a good sign.It was now nearly 11PM, and it did not look like they would get to the district hospital in time. Pandhak made the tough decision to stop the journey in the small bazar of Tukre.“The trip was becoming too long due to the poor road condition and I knew we would never reach the hospital where an emergency doctor and midwife team were on standby to receive us,” Pandhak recounts. “I was very nervous, but knew that the mother was in bad shape and I needed to help somehow.”<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114101136/63720cbe9c7e80680e0b7885jpeg.jpg" alt="" width="1070" height="1600"><figcaption> </figcaption></figure>The two nurses then decided the safest course was to deliver the baby inside the car. In a breech case, the baby’s body is upside down, which means the head is stuck. Pandhak and Khapung tried to help the mother push the baby, while aware that this could injure her.Finally, the nurses managed to carefully pull the baby out, without the mother suffering a serious tear.Read also: <a href="https://www.nepalitimes.com/here-now/saving-one-nepali-mother-at-a-time/" target="_blank" rel="noopener noreferrer">Saving one Nepali mother at a time</a>, Aruna Uprety“I cannot describe the elation and relief that we felt, and I am sure the mother and her relatives were much happier than us, we had delivered a healthy baby inside a cramped car, and mother was also fine,” Pandhak told us on the phone from Tehrathum.After the enroute delivery, the jeep with one extra person on board, continued the journey to Tehrathum District Hospital. When they got there just past midnight, the emergency team could not believe what they saw.Says Pandhak, “They were so proud of us as they took charge of mother and baby at the birthing facility. It was a nerve-wracking experience, but it all ended well.”<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114101136/63720cc19c7e80680e0b7886jpeg.jpg" alt="" width="794" height="854"><figcaption> </figcaption></figure>Pandhak and Khapung are on the frontlines of Nepal’s efforts to <a href="https://www.nepalitimes.com/latest/3-nepali-mothers-still-die-daily-at-childbirth/" target="_blank" rel="noopener noreferrer">reduce maternal and infant mortality</a>. Thirty years ago, 10 in 10,000 women in Nepal used to die in childbirth. That number has come down to 2 in 10,000. But progress has now flat-lined, and 1,500 mothers still die during delivery every year in the country.Even though such individual acts of heroism never make it to the news, it is the work of Female Community Health Volunteers, dedicated Skilled Birth Attendants (SBAs) like Puspa Pandhak and Sumnima Khapung, and local governments that are helping save lives every day across Nepal.In this case, it was also the support for renovating and equipping the birthing centre and midwife training provided by the organisation One Heart Worldwide (OHW) to Menchhhyayem Rural Municipality that helped raise the capacity of the two nurses.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114101136/63720cc39c7e80680e0b7887jpeg.jpg" alt="" width="640" height="853"><figcaption> </figcaption></figure><a style="font-size: 15px; letter-spacing: 0.01em;" href="https://www.nepalitimes.com/banner/what-can-be-more-fulfilling-than-saving-lives/" target="_blank" rel="noopener noreferrer">OHW uses a partnership approach</a> with rural municipalities to upgrade birthing centres through cost-sharing to encourage local ownership. When the work is complete it moves on to other districts.“I still feel so relieved and excited that we saved the lives of the mother and baby, and it was also a life-changing moment for me,” Pandhak says. “I feel so happy to see the family so thrilled. This is the greatest reward that a nurse can ever have.”Pandhak says it was the OHW training that gave her the confidence to make the right decision to deliver in the car and not wait to get to hospital. She adds, “The successful outcome has also given us new confidence to deal with complicated cases in future.”

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Another baby's life is saved in rural Nepal

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022111410114/637204f29c7e80680e0b288djpeg.jpg" alt="" width="1500" height="1000"/><figcaption>Photos: UNICEF NEPAL</figcaption></figure>Despite periods of political and economic instability, Nepal achieved dramatic progress in maternal and child health in the early 2000s becoming an international model.It took great strides in reducing childhood malnutrition, in particular, reducing stunting from 57% in 1996 to 33% in 2016. Maternal and Infant mortality rates also similarly declined, only for much of these successes <a href="https://www.nepalitimes.com/banner/nearly-half-of-nepali-children-still-malnourished/" target="_blank" rel="noopener noreferrer">to stall in the recent years</a>. And this trend has been made worse by the Covid-19 pandemic, states a new UNICEF report.Titled “<a href="https://onlinelibrary.wiley.com/toc/17408709/2022/18/S1" data-saferedirecturl="https://www.google.com/url?q=https://onlinelibrary.wiley.com/toc/17408709/2022/18/S1&amp;source=gmail&amp;ust=1642768390008000&amp;usg=AOvVaw2Qo1HoClES2POc3Qyp2i-7">Nutrition in Nepal: Three decades of progress for children and women</a>”, the report brings together a set of nine original articles that examine the drivers of success and identify where greater policy and programmatic action is needed to achieve the Sustainable Development Goal (SDG) nutrition targets.“Optimal maternal and child nutrition is the basis for developing a resilient society,” says EU Ambassador to Nepal, H.E. Nona Deprez. “The decline in the number of malnourished children, improvements in health facilities and services, and the multisectoral approach used in Nepal over the past three decades are a testament to the Government of Nepal’s commitment to reducing all forms of malnutrition.”A <a href="https://onlinelibrary.wiley.com/toc/17408709/2022/18/S1" data-saferedirecturl="https://www.google.com/url?q=https://onlinelibrary.wiley.com/toc/17408709/2022/18/S1&amp;source=gmail&amp;ust=1642768390008000&amp;usg=AOvVaw2Qo1HoClES2POc3Qyp2i-7">special supplement of the Maternal and Child Nutrition Journal</a> published on Thursday lists some of Nepal’s biggest nutritional achievements. Between 1996-2016, the early initiation of breastfeeding saw an increase from 18% to 56%, and complementary feeding increased from 54% to 77%.During the same period, women taking sufficient iron and folic acid supplements during their pregnancy rose from 6% to 71%. This was combined with earlier and more frequent antenatal care visits.Consistent administering of Vitamin A has saved the lives of an estimated 45,000 Nepali children under the age of five, between 2002 and 2015. Similarly, households using adequately iodised salt doubled from 35% to 77% from 1998 to 2016.Much of this progress can be credited to improvements in household wealth, parental education, and <a href="https://www.nepalitimes.com/banner/toilet-trained/" target="_blank" rel="noopener noreferrer">sanitation</a>. But equally important was increased coverage of health and nutrition services undertaken by successive governments.Nepal Government utilised ground-breaking research to test interventions and overcome challenges, it is also committed to enforcing mandatory legislation such as salt iodisation, writes the journal supplement.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022111410114/637204f69c7e80680e0b288ejpeg.jpg" alt="" width="1500" height="1001"><figcaption></figcaption></figure>Mobilisation of <a href="https://www.nepalitimes.com/latest/enlisting-female-health-volunteers-to-fight-covid-19/" target="_blank" rel="noopener noreferrer">Female Community Health Volunteers</a> (FCHVs) across Nepal villages and towns have improved the health of mother and children, so has an investment in sectoral programs including education and sanitation.But there are now new challenges to achieving national and global targets on nutrition, which also threatens to undermine past gains.“The learning from the past 25 years that are incorporated in the supplement will inform and contribute to future improvements. However, we must act now, given the impact that the pandemic has had on the nutritional health of mothers and their children,” says Elke Wisch, UNICEF Representative to Nepal.During the pandemic, most households experienced job losses or reduced income. With the <a href="https://www.nepalitimes.com/here-now/3rd-wave-in-2-years/" target="_blank" rel="noopener noreferrer">Omicron-led third wave</a> spreading across Nepal, the pandemic’s ensuing socioeconomic crisis is long from over.This means reduced dietary intake among children and mothers. School closures will deprive many children of getting one decent meal a day. All this will add to <a href="https://www.nepalitimes.com/banner/nepals-epidemic-of-hunger/" target="_blank" rel="noopener noreferrer">childhood malnutrition</a> which continues to be a major cause of death and retarded mental and physical development among younger populationsAs such, UNICEF has recommended the government to improve the general public’s access to nutritious, safe, affordable, and sustainable diets. It also suggests integrating essential nutrition services into the existing service delivery platforms like family planning, antenatal, delivery and post-natal care and well-child and sick-child care and continuing to mobilise FCHVs to reach more women and children.To disseminate factual information, advice and counselling on infant and young child feeding, <a href="https://www.nepalitimes.com/here-now/3rd-covid-wave-infects-nepals-frontliners/" target="_blank" rel="noopener noreferrer">healthcare workers</a> can also use multiple communication channels such as radio, TV or social media.But perhaps equally if not more important is strengthening local levels so that they can plan, implement and monitor nutrition programs and services, and maintain Nepal's commitment to generating data, information, and evidence to assess progress and inform decisions.

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Covid undermines Nepal's mother-child gains

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221110141136/636cfe469c7e80680e0a0c2ejpeg.jpg" alt="" width="2529" height="1427"/><figcaption>Photo: HIMALMEDIA</figcaption></figure>A white-coated nurse holding a blue and white, half-litre bag of milk stands in front of a small group of mothers seated near the entrance of the Nutrition Rehabilitation Home in Kathmandu.She is explaining the importance of feeding milk to their children, who are lolling on their mothers’ laps. On a table behind the nurse are containers of pulses and legumes and leaning against the wall, charts displaying leafy vegetables.But later, listening to the women’s stories, it is apparent that solving their children’s problems will require more than a healthy diet. Through tears, Chandra, 24, says she brought her son Raju, 21 months, to the Home after a routine hospital check-up found that he was malnourished.<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221110141136/636cfe499c7e80680e0a0c2fjpeg.jpg" alt="" width="3706" height="2170">His father, who Chandra was forced to marry, bought barely enough food for them to survive, says the woman. That deprivation, plus physical beatings and “mental torture” caused Chandra to flee their village home for Kathmandu.Mother and son arrived in January at the 24-bed facility perched on a hill on the outskirts of the city, where housing colonies sprout on former farm fields. In the month since then, Raju has gained 1kg in weight and is much stronger.The boy will stay at the Home for a few more weeks, says Sunita Rimal, coordinator of the Malnutrition Prevention and Treatment Program at the Nepal Youth Foundation, which runs the Home. By then she hopes to have found some work in Kathmandu for Chandra via her informal channels, so that the mother-son pair don’t have to go back.<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221110141136/636cfe4d9c7e80680e0a0c30jpeg.jpg" alt="" width="901" height="786">Epidemic of hungerNina Parajuli, 45, brought her daughter Anushka, 7, to the Home weeks later on the advice of staff at a local non-governmental organisation. Nina had gone there for skills training after losing her house-cleaning job in Kathmandu.She was forced to find work unexpectedly after Anushka was born, when her husband deserted them. The family that hired her ate their first meal of the day only in the afternoon, which meant the girl left for school in the morning having eaten only snacks, while her mother worked. Eventually, Anushka grew dangerously thin and was considered severely malnourished when she arrived.Nina “was too concerned with her own problems to notice,” Rimal explains. Like her husband, she is HIV positive. She also has a heart condition and is on a waiting list for a uterus operation.Though unique, the stories of Nina and Chandra share a common thread — the causes of their children’s malnutrition are multifaceted. Rimal says that is the norm: “Most of the people who come here have other socioeconomic problems.”Past achievements Nepal is celebrated globally for its success in fighting malnutrition from the 1990s until recent years. Most notably, rates of stunting (low height for age) fell from the world’s highest, 68% in 1995, to 36% in 2016.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221110141136/636cfe509c7e80680e0a0c31jpeg.jpg" alt="" width="2410" height="1064"><figcaption> </figcaption></figure>New research has teased out exactly which development efforts had what impact on stunting. Indirect (also known as ‘nutrition-sensitive’) approaches were surprisingly effective. For example, better educated parents accounted for 25% of the improvement, <a href="https://www.nepalitimes.com/banner/toilet-trained/" target="_blank" rel="noopener noreferrer">environmental factors</a> like building more toilets contributed 12% and economic growth made up 9%.Direct (‘nutrition-specific’) efforts included: improved nutrition of mothers (accounting for 19% of the gain), and maternal and newborn health care (12%), according to the research, published on the website <a href="https://www.exemplars.health/topics/stunting/nepal">Exemplars in Global Health</a>.“The exemplars that we picked were countries that did (development) much faster than others. Nepal is not necessarily the best example but it is an important example,” says Zulfiqar A Bhutta of the Centre for Global Child Health at The Hospital for Sick Children in Toronto, one of the leaders of the research.“One thing is very clear, no one country has done it alone by only investing in health and nutrition sectors,” explained Bhutta via Zoom from Toronto. “And no one country has done it alone by only investing in poverty alleviation strategies. So the truth is that you have to do both in combination.”Nepal has continued that broad approach, investing in health both directly and indirectly, <a href="https://www.nepalitimes.com/banner/nearly-half-of-nepali-children-still-malnourished/" target="_blank" rel="noopener noreferrer">yet the progress has plateaued</a>.<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221110141136/636cfe549c7e80680e0a0c32jpeg.jpg" alt="" width="1628" height="1255">While stunting continues to fall, the 36% rate is greater than the developing country average of 25% and the Asia average of 21.8%. In fact, the country is on target to hit only one of its nutrition goals for 2025 set by the World Health Assembly — for underweight children under 5 — says the <a href="https://globalnutritionreport.org/resources/nutrition-profiles/asia/southern-asia/nepal/">Global Nutrition Report 2020</a>.So what happened?“The one thing that I was surprised by is that inequity has increased,” says Bhutta, “and I have a feeling some of that may have had to do with the urban poor or rural to urban migration.”Nepal, he adds, should work to pinpoint the who’s and why’s of poverty, but otherwise, it should maintain its balanced approach.Investment on nutrition A recent analysis from UNICEF found, however, that spending on indirect approaches to fight malnutrition was rising while declining for direct interventions. This goes against the direction given in the government’s <a href="http://nnfsp.gov.np/PortalContent.aspx?Doctype=Resources&amp;ID=330">Multi-sector Nutrition Plan</a> (MSNP), the blueprint for tackling malnutrition.<a href="https://www.nepalitimes.com/editorial/hunger-for-governance/">Hunger for governance</a>, EditorialThe first phase of the MSNP ran from 2013 to 2017, and the current plan ends next year. The analysis in UNICEF’s <a href="https://www.unicef.org/nepal/media/13296/file/Nutrition%20-%20Budget%20brief.pdf">Nutrition Sector Budget Brief</a> also pointed out that the cost of programs in phase two (Rs48.9 billion) of the multisector plan is just 54% of phase one (Rs88.5 billion). In addition, the gap between budget numbers and actual spending has been growing.Kiran Rupakhetee of the Good Governance and Social Development Division at the National Planning Commission secretariat, helped shape MSNP-II. In an online interview he suggests that rather than the current plan’s budget being too low, the budget for MSNP-I might have been “over calculated at the time”.As to the growing gap between allocations and real spending — it results from many factors, including “rigidities and structural barriers” in the system, he explains.Another major challenge for MSNP-II is federalism, which introduced three levels of government after elections in 2017. “It’s a Herculean task… because at the moment it’s not only one government—we have 761 governments… There are some difficulties in ensuring coordination among them,” adds Rupakhetee.The pandemic challenge The Covid-19 pandemic <a href="https://www.nepalitimes.com/latest/covid-19-leaves-millions-of-south-asian-children-hungry/" target="_blank" rel="noopener noreferrer">has added to the challenge</a>. “It definitely has hampered our activities,” says Rupakhetee, “but we tried our level best to keep the programme going.”For example, parents were trained to measure the arm circumference of infants to detect signs of malnutrition, a task usually done by female community health volunteers, who have been unable to do so due to frequent lockdowns.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221110141136/636cfe579c7e80680e0a0c33jpeg.jpg" alt="" width="960" height="640"><figcaption> </figcaption></figure>Nepal’s school feeding programme was also modified because of the pandemic, with food rerouted to students’ homes, says World Food Programme (WFP) Country Director Jane Pearce, in an online interview.“Whereas most of the world stopped all of their school meals programmes, Nepal has continued, which has meant that we’re maintaining the nutrition that we’re providing through our locally-managed school meals programmes by giving households take-home rations,” she said.WFP has also teamed up with UNICEF and other UN agencies to press the government to expand its malnutrition treatment to include not only children who are severely wasted (low weight for age) but moderately wasted, says WFP’s Head of Nutrition Anteneh Girma.“With the impact of Covid and others, if they’re not treated they will become severely malnourished, then chronically malnourished, or stunted,” he adds.In June <a href="https://www.nepalitimes.com/banner/nepals-epidemic-of-hunger/">this paper reported</a> on how severe malnutrition was killing children in the poorest communities in Nepal’s eastern plains. It told the story of Raju Devi Sada, whose first daughter died at 3, after being malnourished. A second daughter died soon after birth, a year later.A third daughter is underweight and local health workers have recommended feeding her nutritious food. But Raju Devi cannot afford vegetables, eggs, milk and meat, and what she earns as a daily wage labourer is barely enough to feed the rest of the family.“We have found that up to 70% of children who die every year in Province 2 do so due to malnutrition, and the main reason for that is extreme poverty,” said Kedar Parajuli at Nepal’s Family Welfare Division. “Without alleviating poverty, we can’t solve malnutrition.”WFP is doing mapping, using mobile data, to create what it calls a vulnerability index. It documents people’s access to water and sanitation services, health and other factors, in addition to nutrition, says Girma.He adds, “Our nutrition response, food security response, is informed by that index… it indicates those who are vulnerable for not having access on time, for being exposed to various inequalities.”The private sectorGirma points out that WFP, both in Nepal and globally, supports the multisector approach. In that vein, the UN agency is working closely with the government to establish the <a href="https://sunbusinessnetwork.org/">Scaling Up Nutrition (SUN) Business Network</a> in Nepal. To date, 10 companies, all working in the food industry, have become members.Ending malnutrition and other food-related diseases “will happen only if the private sector is responsible for what they are producing, and producing something safe …  so their engagement, bringing them to the table, is very important,” says Girma.Leading collaboration with the private sector on the ground is <a href="https://www.baliyonepal.com/en/">Baliyo Nepal</a>, a non-profit company that generated headlines when it launched in 2019. The initiative was funded by the Bill &amp; Melinda Gates Foundation through the Chaudhary Foundation, the charity arm of the Chaudhary Group, makers of Wai Wai instant noodles, which are widely considered junk food.<a style="font-size: 15px; letter-spacing: 0.01em;" href="https://www.nepalitimes.com/banner/junk-food-is-making-nepali-children-shorter/" target="_blank" rel="noopener noreferrer">Junk food is making Nepali children shorter</a>, Marty LoganToday Baliyo Nepal is set to expand a pilot project that has been running in Lumbini Province since 2020 — raising awareness about nutritious food among school children, including via a cricket program, and educating shopkeepers to sell the nutritious foods in the first phase of its ‘Baliyo Basket’: eggs and a single-portion Rs10 sachet of fortified porridge for infants.“Seventy percent of the sachets in the market were sold, according to the sales report,” says Baliyo Nepal CEO Atul Upadhyay, a nutritionist, in an interview in his Kathmandu office. “The feedback we’re getting from mothers is ‘Now we want it in a bigger package. We can’t go to the shop every day and buy the Rs10 package’.”Upadhyay says manufacturers will start making the larger packs by year end. That is just one of many plans he is cooking up — besides expanding pilot activities to Bagmati and Gandaki provinces, the company will soon be adding to its Baliyo Basket a fortified drink for pregnant and lactating women and fortified porridge for 2-5-year-olds, once they are approved by the government.Upadhyay notes that both the government and private sector are gradually embracing his innovative approach but stresses that new ways to fight malnutrition, like this public-private partnership model, are essential if Nepal is to reach its nutrition targets.“It’s not important who works for nutrition. It’s important that someone works for nutrition, whether it be WFP, Baliyo Nepal, company A, company C — I don’t mind,” he adds.Target StuntingStunting, low height for age, is a sign of chronic undernutrition. It can hinder brain development resulting in reduced mental ability and learning capacity, poor school performance in childhood and lower earnings and higher risks of nutrition-related chronic diseases, such as diabetes, hypertension and obesity, in adulthood.Nepal cut its stunting rate dramatically in recent decades, and it is one form of malnutrition that the country might be on track to reduce in line with coming targets: MSNP-II (2022), World Health Assembly (2025) and SDGs (2030).The UNICEF Nutrition Sector Budget Brief says that the average yearly rate of stunting reduction since 2001 (3.25%) must increase to 3.8% to meet the MSNP-II and WHA targets, and rise to 6.5% to meet the SDG target.According to Kiran Rupakhetee at the National Planning Commission: “The Nepal Multiple Indicator Cluster Survey has brought some encouraging results, but it may still be difficult to make the WHA target... but since the SDGs deadline is quite far away I’m very much optimistic and hopeful that we can meet it.”Stunting rates and targets 2016: Nepal Demographic and Health Survey – 36%2019: Nepal Multiple Indicator Cluster Survey – 31.5%2022:  Target: Multi-sector Nutrition Plan-II – 28%2025:  Target: World Health Assembly – 25%2030:  Target: SDGs – 15%

Marty Logan

A tall order

<img width="1169" height="747" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221110151120/636d08ca9c7e80680e0a603ajpeg.jpg" alt=""/>The Human Rights Watch (HRW) on Tuesday wrote a letter to Prime Minister Sher Bahadur Deuba, urging him to uphold the rights of Nepali citizens and strengthen the rule of law.
Recent <a href="https://www.thelancet.com/action/showPdf?pii=S2214-109X(20)30345-4">reports</a> have revealed that the pandemic has decreased institutional delivery by half, increasing risks of premature birth, stillborn deliveries and newborn deaths, setting back Nepal’s past gains in maternal and child care.
Additionally, reduced family income coupled with prolonged school closures has pushed many Nepali children into labour, with projections that half of the girl students may not rejoin schools once they <a href="https://www.nepalitimes.com/latest/half-of-nepals-girls-may-drop-out-of-school/">reopen</a>. Child marriages are on the rise.
“The new government should take measures to safeguard and continue progress on health and education, including through assistance for households whose livelihoods have been devastated by the pandemic,” says Meenakshi Ganguly, South Asia director at Human Rights Watch. “Safety nets are critical for ensuring that crises do not prevent children from continuing their education or harm progress on reducing child marriage and child labour.” 
The letter paid special attention to pressing human rights issues pertaining to Nepal’s failures in addressing war crime and transitional justice.
In 2015, Nepal formed the Truth and Reconciliation Commission and the Commission of Investigation on Enforced Disappeared Persons. A year before that in 2014, the Supreme Court scrapped provisions in the transitional justice law that allows amnesty for offences including torture, murder, and enforced disappearance during Nepal’s armed conflict. The law has not been revised.
Successive governments have stopped conflict-era cases from being heard in regular courts citing the supposed transitional justice process, even as victim groups and Nepali human rights organisations have long questioned its credibility. 
But their protests seem to have fallen on deaf ears, one of Deuba’s first acts in office was to extend the terms of transitional justice commissioners by another year.
“Successive governments have stalled on delivering justice to victims for the many grave cases of abuse, preferring to protect the abusers instead,” adds Ganguly. “As a result, abuses continue while principles of accountability, the rule of law, and the independence of institutions have been eroded, with negative consequences for everyone in society.”
Nepal has made little progress in investigations of human rights violations at home despite being re-elected as a member of the United Nations Human Rights Council. This has had a corrosive impact on wider principles of accountability and the integrity of institutions.
Of late, Nepal has seen a marked increase in alleged extra-judicial killings, custodial deaths allegedly from torture, and the excessive use of lethal force against protesters. In fact, the NHRC in October 2020 published a list of 286 suspects of serious crimes that included law enforcement officials, military personnel, and former Maoist insurgents that police had refused to investigate.
A culture of impunity has undermined the rule of law, there is no accountability for abuses of power. Instead, they continue to climb up the bureaucratic ladder, like the promotion of a police officer alleged to be involved in the extra-judicial killing of two men in August 2018. 
Justice and relief for survivors of sexual violence during the conflict is even more difficult to come by. On the other hand, families of six young Dalit men murdered in Rukum in May 2020 —among the deadliest instances of caste-based killings in Nepal, still await justice. Those linked to the death of a 12-year-old girl forced to marry her rapist in May 2020 have yet to be held accountable.
The HRW has also called on the Deuba government to reverse appointments made to independent institutions like NHRC and the Election Commission after the Oli government pushed an ordinance amending the law in December 2020 to allow only three members of the Council to make appointments.
There are numerous other pending challenges such as the 2006 Citizenship Act, provisions in the 2015 Constitution, and a draft citizenship bill that limits women’s ability to transmit citizenship through marriage. The bill is similarly discriminatory against Nepal’s transgender people.
The HRW also opposed restrictions on the freedom of religion, rights to peaceful assembly, expression, and association of Tibetan refugees in Nepal who have fled Chinese persecution.
Says Ganguly: “Prime Minister Deuba faces many pressing problems, but he also has an opportunity to craft a positive legacy. Meanwhile, Nepal’s international development partners should press the government for measurable action on accountability if they hope to achieve change.”

Nepal must work on human rights

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109111144/636b84729c7e80680e067796jpeg.jpg" alt="" width="1500" height="1125"/><figcaption>Rita Khatri, 21, is the only skilled birth attendant in her village of Phediguth of Okhaldhunga district, where she has helped to promote institutional birthing despite the challenges posed by the pandemic. All photos: NARESH NEWAR</figcaption></figure>Unlike many of her nursing colleagues who yearn to go abroad or find a job in a city hospital, Rita Khatri returned to her home village in Okhaldhunga after completing her training as a skilled birth attendant in Kathmandu.It was not easy for the 21-year-old to be taken seriously by her own community in Phediguth village of Champadevi Municpality, she had to earn their trust and respect one safe delivery at a time.But just as families in surrounding villages came to depend on her for vital <a href="https://www.nepalitimes.com/latest/3-nepali-mothers-still-die-daily-at-childbirth/" target="_blank" rel="noopener noreferrer">prenatal care and safe deliveries</a>, the Covid-19 pandemic hit. Now, on top of all the other health challenges in rural Nepal, there is the additional danger of being infected with this contagious new strain of the coronavirus that has spread across the country.Because of its remoteness and lack of connectivity, the pandemic has not affected this scenic district of eastern Nepal as seriously as other parts of the country. Still, there are 90 active Covid-19 cases in the district and a dozen people on average test positive every day.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109111144/636b84769c7e80680e067797jpeg.jpg" alt="" width="1500" height="1125"><figcaption> </figcaption></figure>Being a trained midwife, Rita Khatri’s main worry is that restrictions on travel and fears about the <a href="https://www.nepalitimes.com/here-now/birth-and-death-during-a-pandemic/" target="_blank" rel="noopener noreferrer">virus will affect maternal and neonatal health services</a> as most villagers are afraid to visit her birthing centre for check-ups and deliveries.“I am scared that the pandemic will set back all the work we have done here to reduce home deliveries and to improve maternal and infant survival,” Khatri says. “We had finally managed to convince families to opt for institutional birthing, but that might now change.”Staff at the centre are also worried about their safety, since this <a href="https://www.nepalitimes.com/editorial/this-is-war/" target="_blank" rel="noopener noreferrer">second wave is much more deadly</a> than the one in 2020. Last year, Khatri had helped mothers even when most government health posts had shut down in the districts, many staff were afraid to come to work, and if they did were afraid to even touch their patients.But Khatri kept the birthing centre open, and carried out 32 deliveries in 2020, some of them complicated ones where the <a href="https://www.nepalitimes.com/here-now/birth-and-death-during-a-pandemic/" target="_blank" rel="noopener noreferrer">mothers’ life would have been in danger</a> if they had given birth at home.“Closing down would have meant risking the lives of many mothers,” says Khatri, who has been trying to convince as many families as possible who are under her care that it was safe to visit the birthing centre.https://www.youtube.com/watch?v=ESmZURVRyN4It is much more difficult this year to convince both mothers and staff. Still, Khatri says, “I am also apprehensive about being infected, but I am the only SBA around here, and I want to ensure as many <a href="https://www.nepalitimes.com/banner/infant-deaths-up-during-nepal-lockdown/" target="_blank" rel="noopener noreferrer">institutional deliveries</a> as possible and save mothers and their babies from risking home births.”Khatri says that for her, nursing is not just a job. It is an occupation through which she wished to serve her community where there is no doctor for miles around. There is a steely determination in her thin voice as she says, “I will keep my doors open no matter how bad the pandemic is, this is what I was trained to do.”The community has a new esteem for Rita Khatri because of the dedication and hard work she displayed last year, and villagers are glad that they have her to go to for <a href="https://www.nepalitimes.com/opinion/newborn-deaths-and-a-vision-for-a-post-pandemic-nepal/" target="_blank" rel="noopener noreferrer">safe motherhood</a>.It has not been easy for Khatri to earn this trust. When she first returned home to Okhaldhunga to join Phediguth Health Post, villagers heard that a new ‘doctor’ had arrived. But when they came to visit, they were visibly disappointed that it was just a girl they knew from the village.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109111144/636b847a9c7e80680e067798jpeg.jpg" alt="" width="1500" height="1125"><figcaption> </figcaption></figure>But within a few months, Khatri proved herself through her profesionalism and ability to handle the most complicated maternity cases at the birthing centre which was upgraded with help from the non-profit, <a href="https://www.nepalitimes.com/banner/what-can-be-more-fulfilling-than-saving-lives/" target="_blank" rel="noopener noreferrer">One Heart Worldwide</a> (OHW).Not every delivery goes right, there are some which need specialist treatment or caesarian sections, others suffer post-partum haemorrhage and some mothers are already in a critical condition because they are brought to the centre too late. When the mother or child cannot be saved, Khatri has sometimes been slapped, kicked and verbally abused by angry relatives.“I could understand their frustration, but I did not let anything demoralise me,” says Khatri. “I was trying to the best of my ability to save their lives.”Today, everyone respectfully calls Khatri ‘Sister’, and some even call her ‘Doctor’. Many also have apologised for mistreating her in the past, and come bearing gifts to show their gratitude. “I refuse to take them because I am just doing my duty,” Khatri tells us.Champadevi Health Post has upgraded its maternity room, but there are many others across Nepal that are struggling with <a href="https://www.nepalitimes.com/banner/this-is-how-to-upgrade-nepals-rural-health/" target="_blank" rel="noopener noreferrer">proper buildings, equipment and staff</a>. The biggest challenge is the lack of nurses trained as skilled birth attendants.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109111144/636b847d9c7e80680e067799jpeg.jpg" alt="" width="1500" height="1125"><figcaption> </figcaption></figure>When Rita Khatri joined the Phediguth Health Post, its birthing centre did not have proper equipment, not even a maternity bed for deliveries. Most deliveries happened late at night without electricity, and mothers were in prolonged labour sometimes lasting 16 hours. Some of Khatri’s patients preferred lying on the floor to give birth because they found the table that served as a maternity bed so uncomfortable.Without electricity, staff had to stumble in the dark during deliveries, and it was difficult to keep the maternity room warm without heaters. Khatri tried unsuccessfully with the local government to get power supply, but it was One Heart Worldwide that installed solar-powered lights. Little by little, the facility was improved to be the clean and bright birth centre it is today.Khatri is modest about her accomplishment: “This is the least I could do for my birthplace, so giving birth is safe."To donate to Phediguth Health Post: Account name: Phediguth Health PostRastriya Banijya Bank, OkhaldhungaAccount number 207000290101

Saving Nepali mothers on Mother’s Day

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221110111152/636cd8879c7e80680e092e49jpeg.jpg" alt="" width="1500" height="1125"/><figcaption>Phediguth village in Okhaldhunga where poor roads make access to health facilities difficult for complicated maternity cases. All photos: NARESH NEWAR</figcaption></figure>Stories of birthing are not the kind of conversation that children in Nepal usually have with their mothers. Surya Bhatta’s career path, however, took a new turn when his mother shared her own story of how she survived a near-death complication when she was giving birth to his elder sister.His mother was married at 11, and had her first baby at 16. Access to health services in their home village in Dhading was limited at the time, and she suffered from severe postpartum complications.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221110111152/636cd88b9c7e80680e092e4ajpeg.jpg" alt="" width="640" height="364"><figcaption> </figcaption></figure>“Luckily, my mother survived but we all know many Nepali mothers still face similar risks due to poor maternal health,” says Bhatta, now executive director of One Heart Worldwide (OHW), a US-based organisation working in Nepal.At 34 Bhatta is proud to be playing a role to save the lives of mothers like his mother. Although the country has made vast improvements in reducing the maternal mortality rate from 539 per 100,000 live births 25 years ago to 240 today, it is still unacceptably high.An estimated 2,000 new <a href="https://www.nepalitimes.com/here-now/who-will-save-nepals-poor-new-mothers/" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/here-now/who-will-save-nepals-poor-new-mothers/&amp;source=gmail&amp;ust=1615874753197000&amp;usg=AFQjCNEu5wCZ54G1e7vKzay3LB7DTXI7mA">mothers still die</a> in Nepal every year —  most of them because health posts are not properly equipped and staffed. The maternal mortality rate also went up in 2020 because the lockdown and pandemic prevented many mothers from getting to hospitals or birthing centres.Bhatta and his colleagues have been working to improve maternal neonatal health care, and with a 70-strong team is setting up birthing centres and hospitals in Nepal’s most remote districts to upgrade care for mothers and babies.<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221110111152/636cd88e9c7e80680e092e4bjpeg.jpg" alt="" width="200" height="191">Starting from five villages of Baglung in 2010, One Heart has expanded to 21 districts and helped renovate and equip more than 500 birthing centres in 164 municipalities where road access is still limited. The centres work with local municipalities on a cost-sharing public-private-partnership formula.https://www.youtube.com/watch?v=tVA--CRk3nMMany government health posts in rural municipality wards are under-resourced and often struggle to even buy standard maternity delivery beds and lifesaving equipment. There is inadequate <a href="https://www.nepalitimes.com/banner/federalism-leaves-nepals-medical-sector-ailing/" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/banner/federalism-leaves-nepals-medical-sector-ailing/&amp;source=gmail&amp;ust=1615874753197000&amp;usg=AFQjCNEX5KH1MBkZwv3gDbQd0uKEItLdXg">infrastructure</a> for pre-natal, delivery and post-natal care, and a chronic shortage of trained midwives in rural areas.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221110111152/636cd88f9c7e80680e092e4cjpeg.jpg" alt="" width="1500" height="1710"><figcaption> </figcaption></figure>Nurses are not trained to handle complicated cases during and after delivery, and as frontline maternity workers face the wrath of local communities when mothers and babies die.Bhatta and his team have zeroed in on training nurses at health posts to become skilled birth attendants, an intervention that directly saves lives. One Heart’s trained nurses and renovated birthing centres now care for more than 72,000 pregnant women across Nepal annually.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221110111152/636cd8929c7e80680e092e4djpeg.jpg" alt="" width="1500" height="1125"><figcaption> </figcaption></figure>“Even during the pandemic rural municipalities were able to find resources to share half the cost of construction to renovate the birthing centres,” says Bhatta who works in partnership with local governments and community groups.Bhatta sets program priorities after consultation with local elected representatives, tries to raise money locally, and then tops it up by competing globally for international grants. He says, “We can’t make our people always dependant on international aid. We need to be innovative by taking risks with new ideas.”<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221110111152/636cd8959c7e80680e092e4ejpeg.jpg" alt="" width="1500" height="1125"><figcaption> </figcaption></figure>The partnership approach for upgrading birthing centres through cost-sharing is innovative, and one that encourages local ownership, clearly outlining outcomes. It went ahead because local governments under Nepal’s new federal structure were willing to start implementation immediately.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221110111152/636cd8989c7e80680e092e4fjpeg.jpg" alt="" width="1500" height="1125"><figcaption> </figcaption></figure>“Entrepreneurship is needed in the social sector not for profit making, but for creating quality service that can go up to scale,” explains Bhatta. “Social entrepreneurship is all about evidence-based work that guide organisations to reduce risks and help improve through sustainable local health systems. There are challenges in Nepal, but there are so many opportunities to overcome them through partnerships like this.”<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221110111152/636cd89b9c7e80680e092e50jpeg.jpg" alt="" width="1500" height="964"><figcaption> </figcaption></figure>Bhatta makes a case for Nepalis to return home after higher education overseas, just as he himself did after graduating from Dartmouth in the United States, fulfilling the promise he had made to his mother that he would make a difference for as many Nepali mothers like her as possible.He says, “I am proud of the team we have built, I feel we are making a difference especially for rural communities. What can be more fulfilling than helping save lives?

“What can be more fulfilling than saving lives?”

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022110915118/636bb4569c7e80680e07bb98jpeg.jpg" alt="" width="640" height="427"/><figcaption>Photo: OM ASTHA RAI/NEPALI TIMES ARCHIVE</figcaption></figure>The world recorded an all-time low under-five deaths in 2019, but the COVID-19 pandemic has resulted in major disruptions to health services that threaten to undo decades of hard-won progress and put millions of additional lives at stake.There were 5.2 million children who died of preventable causes last year, compared to 12.5 million in 1990. But UNICEF, the World Health Organisation (WHO) and World Bank say the pandemic may force the mortality rate up again.“The global community has come too far towards eliminating preventable child deaths to allow the Covid-19 pandemic to stop us in our tracks,” says HenriettaFore, UNICEF Executive Director. “When children are denied access to health services because the system is overrun, and when women are afraid to give birth at the hospital for fear of infection, they, too, may become casualties of COVID-19.”Indeed, although SARS-CoV-2 seems to <a href="https://www.nepalitimes.com/latest/why-are-younger-people-in-poor-countries-dying-of-covid-19/" target="_blank" rel="noopener noreferrer">spare the younger population</a>, disruptions in medical care and in the supply chain for essential medicines is leading to a spike in non-coronavirus fatalities among children.For instance, the under-5 child mortality rate in Nepal had declined substantially from 271 deaths per 1,000 live births in 1969 to 31 in 2019 -- a dramatic 78% reduction from 1990 levels.Health services to prevent or treat causes of child death such as preterm, low birth weight, complications during birth, neonatal sepsis, pneumonia, diarrhoea and malaria, as well as vaccination, have played a large role in this progress.But following Covid-19 lockdown, Nepal saw a <a href="https://www.nepalitimes.com/banner/children-are-collateral-damage-in-nepal-lockdown/" target="_blank" rel="noopener noreferrer">30% increase in the number of under-fives who have died</a> in the March-April-June this year compared to the same period last year – mainly due lack of transport to take sick children to hospital, or reluctance to seek medical attention because of the fear of the virus.A rapid assessment conducted by UNFPA in coordination with Family Welfare Division during the initial phase of the lockdown period in Nepal also reported more than 60% decline in antenatal visits and 35% <a href="https://www.nepalitimes.com/banner/infant-deaths-up-during-nepal-lockdown/" target="_blank" rel="noopener noreferrer">decrease in institutional delivery as compared to before the restriction</a>.A UNICEF survey conducted over the past few months across 77 countries found that almost 68% of countries reported disruption in health checks for children and immunisation services, 63% in antenatal checkups and 59% in post-natal care.A recent WHO survey in 105 countries revealed that 52% of countries were experiencing disruptions in health services for sick children and 51% in services for management of malnutrition.“The fact that today more children live to see their first birthday than any time in history is a true mark of what can be achieved when the world puts health and well-being at the centre of our response,” says Tedros Adhanom Ghebreyesus, WHO Director-General. “Now, we must not let the COVID-19 pandemic turn back remarkable progress for our children and future generations.”Based on the responses from countries that participated in the surveys, the most commonly cited reasons for health service disruptions included parents avoiding health centres for fear of infection, transport restrictions, suspension or closure of services and facilities, fewer healthcare workers due to diversions or fear of infection due to shortages in personal protective equipment, and greater financial difficulties.Back in May, initial modelling by Johns Hopkins University also showed that <a href="https://www.nepalitimes.com/latest/pre-existing-diseases-may-kill-more-children/" target="_blank" rel="noopener noreferrer">6,000 additional children worldwide could die per day</a> due to disruptions due to COVID-19.To be sure, <a href="https://www.nepalitimes.com/opinion/newborn-deaths-and-a-vision-for-a-post-pandemic-nepal/" target="_blank" rel="noopener noreferrer">newborns</a> across the world were at highest risk of death even before Covid-19 pandemic. In 2019, a newborn baby died every 13 seconds. Moreover, 47% of all under-five deaths occurred in the neonatal period, up from 40% in 1990. Severe disruptions in essential health services due to Covid-19 have only added to the challenge.Says John Wilmoth, Director of the Population Division of the UN Department of Economic and Social Affairs, “While this report highlights the negative effects of the Covid-19 pandemic, it also draws attention to the need to redress the vast inequities in a child’s prospects for survival and good health.”

Covid-19 to reverse child survival gains

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221129151140/638619f69c7e80680e0cccd2jpeg.jpg" alt="" width="1500" height="844"/><figcaption>Photo: MARTY LOGAN</figcaption></figure>It should not be surprising that <a href="https://www.nepalitimes.com/latest/the-story-of-nepals-first-covid-19-fatality/" target="_blank" rel="noopener noreferrer">Nepal’s first COVID-19 death was a new mother</a>. What was surprising was to hear Prime Minister K P Oli admitting in Parliament on Tuesday that Nepal’s coronavirus deaths represented a failure of his government.<a style="font-size: 15px; letter-spacing: 0.01em;" href="https://www.nepalitimes.com/banner/3rd-month-of-lockdown/" target="_blank" rel="noopener noreferrer">Three Nepalis have died with coronavirus</a> since the pandemic hit Nepal. But that is the number of mothers who died every day across Nepal at childbirth. Despite dramatic strides in reducing the <a href="https://www.nepalitimes.com/here-now/who-will-save-nepals-poor-new-mothers/" target="_blank" rel="noopener noreferrer">maternal mortality</a> rate, 1,200 mothers still die while giving birth every year.Government statistics show that this number has risen dramatically in March and April, as women avoid hospitals because of the COVID-19 scare, as well as because of the lack of transport during the lockdown.The 29-year-old woman from Sindhupalchok, whose name has not been released, died on 16 May of post-partum sepsis and a <a href="https://www.nepalitimes.com/here-now/bhaktapurs-covid-19-heroes/" target="_blank" rel="noopener noreferrer">coronavirus infection</a> 10 days after safely delivering her baby at Teaching Hospital in Kathmandu, then returning home. There were delays in taking her to hospital after complications because the family could not find an ambulance.Even before the COVID-19 crisis, one of the reasons far too many Nepali women still give birth unsafely at home was the <a href="https://archive.nepalitimes.com/regular-columns/Comment/mothers-in-Nepal-still-dying-at-childbirth,1007" data-saferedirecturl="https://www.google.com/url?q=https://archive.nepalitimes.com/regular-columns/Comment/mothers-in-Nepal-still-dying-at-childbirth,1007&amp;source=gmail&amp;ust=1590230096851000&amp;usg=AFQjCNHGPAy4FgQc1EbtnlKIZJMxrFl6XA">high cost of ambulance</a> to take them to health facilities.Nepal has made <a href="http://archive.nepalitimes.com/article/nation/people-politics-placentas-child-delivery-complications,3922" target="_blank" rel="noopener noreferrer">progress in reducing maternal mortality</a> and <a href="https://www.nepalitimes.com/banner/born-in-nepal/" target="_blank" rel="noopener noreferrer">newborn deaths</a> thanks to the Safe Motherhood program, for which it received global recognition. But that improvement was nowhere enough to conclude that the job was done and the country could rest on its laurels.Figures show that in 1990, 901 women died per 100,000 births. That number was slashed to 239 per 100,000 live births in 2015. Yet the target for 2030 under the global Sustainable Development Goals is less than 70.If the health of pregnant women is still a government priority it has not been obvious during the lockdown. Pregnant women have been too fearful to visit clinics for crucial antenatal checkups, but by now arrangements should have been made for them to do so safely — or alternatives put in place — and those plans communicated to women.Of course, post-partum mothers are not the only Nepalis dying because of the broken health system. <a href="https://www.nepalitimes.com/here-now/kidney-patients-dying-due-to-covid-19-lockdown/" target="_blank" rel="noopener noreferrer">Non-communicable diseases </a> NCDs) are now the cause of most deaths in the country, led by heart disease, lung disease and stroke, but an NCD Multisectoral Action Plan spanning 2014-20 has yielded no visible results.The main causes of maternal mortality include post-partum bleeding, unsafe abortions, high blood pressure and post-delivery infection. Abortions aside — because there is still stigma attached to having one and a lack of knowledge about their legality — the other causes are treatable.Some initiatives have been taken. The President’s Women Uplift Program has used helicopters to rescue dozens of pregnant or post-partum mothers in emergency situations and many local governments have started programs to cajole or coerce women to give birth in facilities andto properly care for themselves and their newborns in the crucial days following delivery. But too many health facilities that should be providing services to pregnant women remain <a href="https://www.nepalitimes.com/here-now/who-will-save-nepals-poor-new-mothers/" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/here-now/who-will-save-nepals-poor-new-mothers/&amp;source=gmail&amp;ust=1590230096851000&amp;usg=AFQjCNEb9E7sQYw1XzmTTnMfGji3UmNybQ">under-staffed, ill-equipped and short of medicines</a>, and there is no visible national action plan, certainly no sense of urgency.Contrast media coverage of deaths of new mothers with those of women and girls practising chhaupadi in far western Nepal. Temporarily exiled from their homes during menstruation or after giving birth, they are at risk of snakebite, asphyxiation in tiny, windowless huts, and rape and physical assault. While outlawed, the practice continues.In recent years chhaupadi has been reported widely in Nepal and garnered numerous headlines in major global media. Yet, while roughly 15 women have died in <a href="https://www.nepalitimes.com/opinion/tipping-point-on-menstrual-banishment-in-nepal/" target="_blank" rel="noopener noreferrer">chhaupadi</a> in Nepal since 2010, there have been 15,000 women who died in that time from causes associated with giving birth. For much of the media, death during pregnancy has become too routine to deserve coverage.The prime minister was right to admit failure over the COVID-19 deaths to date: his government <a href="https://www.nepalitimes.com/latest/has-nepals-lockdown-just-postponed-covid-19/" target="_blank" rel="noopener noreferrer">has had ample time to craft a much more effective response, and has not</a>  The deficits in the health system overall have been evident, and discussed, throughout the decades that the prime minister and his colleagues in all parties have been in power. That deserves an admission of failure, followed by corrective action.

3 Nepali mothers still die daily at childbirth

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022110912114/636b8a0f9c7e80680e06b21djpeg.jpg" alt="" width="1182" height="665"/><figcaption>Photos: MARTY LOGAN</figcaption></figure>According to a recent journal article, it will be 2067 before newborn deaths among the poorest Nepalis have fallen enough to reach the global target set for 2030. That target, of 12 or fewer deaths per 1,000 live births, was attained by the wealthiest in Nepal four years ago, but the impact of COVID-19 may increase inequality and make it even more difficult for the country to reduce infant mortality.If the pandemic shutdown is an opportunity to reimagine our societies, what should Nepal make of the widening gap in newborn deaths? Yes, overall trends are improving — both maternal and newborn health have made major gains in recent decades — but the poorest families are still lagging behind.No society is free from inequality. <a href="https://www.cnbc.com/2018/07/19/income-inequality-continues-to-grow-in-the-united-states.html" data-saferedirecturl="https://www.google.com/url?q=https://www.cnbc.com/2018/07/19/income-inequality-continues-to-grow-in-the-united-states.html&amp;source=gmail&amp;ust=1586065810924000&amp;usg=AFQjCNEFDkgItYw8PUn4d6eLq1PoONAItg">Look at the US</a>: the top 1 percent of families took home an average of 26 times as much income as the bottom 99 percent in 2015. In my home country of Canada, Indigenous people on average live <a href="https://www.cbc.ca/news/health/indigenous-people-live-15-years-less-philpott-briefing-1.4500307" data-saferedirecturl="https://www.google.com/url?q=https://www.cbc.ca/news/health/indigenous-people-live-15-years-less-philpott-briefing-1.4500307&amp;source=gmail&amp;ust=1586065810924000&amp;usg=AFQjCNEImZoC1uNArJawQRbVx3xsgsdD5A">15 fewer years than others</a>.The <a href="https://link.springer.com/article/10.1007/s10995-019-02826-0" data-saferedirecturl="https://www.google.com/url?q=https://link.springer.com/article/10.1007/s10995-019-02826-0&amp;source=gmail&amp;ust=1586065810924000&amp;usg=AFQjCNHiBxpkwQnhtvtVzd8qq56roA-iGg">study in the Maternal and Child Health Journal</a> found that the mortality rate in Nepal of newborns (up to 28 days old) across all socioeconomic groups in 2001–2016 ‘shows significant disparities between different population groups, and that all these disparities either widened or remained constant over the 15-year period’.A secondary analysis of data from the 2001, 2006, 2011 and 2016 Nepal Demographic and Health Surveys, the study added: ‘In 2016, women who had not received a tetanus vaccination had the highest risk of neonatal mortality, followed by women with no education. Other factors ... were giving birth before the age of 20, household air pollution, belonging to a poorest quintile, residing in a rural area, and having no toilet at home.’The authors suggests that a multi-sectoral approach will be needed to improve the neonatal death rate (23 deaths per 1,000 live births in 2015) among all groups. Noting the current decentralisation of health care to provinces and local governments they add: ‘The engagement of the education, healthcare, water and sanitation sectors and of local communities and leaders for the development of their areas will go a long way to overcoming social determinant to neonatal health and survival.’<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022110912118/636b8a119c7e80680e06b21ejpeg.jpg" alt="" width="1182" height="665">One thing the COVID-19 pandemic has revealed is how precariously most people live today, even in the ‘wealthy’ west. I was taught to always keep the equivalent of three months’ salary (or was it six months?) aside for a rainy day. That was 30 years ago. Today in places including Canada, and especially the US, being without work for a couple of weeks is devastating to many people, leaving them unable to pay their rent or mortgage, vehicle loans or credit card payments.Among the poorest of the poor in Nepal, loss of work can quickly lead to families missing meals. As Bikash Gauchan of Achham’s Bayalpata Hosptial <a href="https://www.nepalitimes.com/opinion/poverty-the-real-pandemic/" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/opinion/poverty-the-real-pandemic/&amp;source=gmail&amp;ust=1586065810924000&amp;usg=AFQjCNFW3k8t0NyTkax0cdBZxcT0VO7bSg">recently pointed out</a>, if a coronavirus outbreak occurs in western Nepal it will not be an extraordinary burden for people, because poverty there means that they already shoulder a much heavier load than other Nepalis.<a href="https://www.nepalitimes.com/banner/nepals-great-income-divide/" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/banner/nepals-great-income-divide/&amp;source=gmail&amp;ust=1586065810924000&amp;usg=AFQjCNEv_T0YCJlDTPrWCuzTaWyAZKpaVQ">And that gap is growing</a>. While remittances from Nepali workers abroad have helped reduce overall poverty, 10% of rich Nepalis now own property worth 26 times more than the 40% of the poorest. The Karnali government had spent only 11% of its annual development budget in the first 8 months of the current year. In a province that ranks lower than all the others by most indicators, how could leaders fail to spend money earmarked to improve life for their citizens? Even if their attempts failed, that would still be preferable to doing nothing.In coming months as the pandemic subsides (at least its first wave) will the new New Nepal be content to resume cutting more trees, mining rivers, and clearing land to make way for new and bigger roads? Or can it instead seriously contemplate where it is headed and why many Nepalis are not included on the journey?In terms of development indicators, and not just for newborn mortality, the easy work has been done. Population-wide measures like pre-natal checkups for pregnant women, deliveries in health facilities and getting help to treat pneumonia, are in place. What remains is to ensure that all Nepalis, including the least educated, most remote and the truly marginalised, receive the same treatment. This will take a larger, more focussed effort and above all, a consensus and determination that a 50-year gap between rich and poor is unacceptable.

Newborn deaths and a vision for a post-pandemic Nepal

Lack of access to and awareness of family planning, the prevalence of unhealthy superstitions and taboos, and the desire to produce a son together explain why Nepal’s average fertility rate has stalled after a steep drop in the last decades.Many families in the far western hills and the central Tarai still believe that contraceptive use is against god’s wishes. These areas also tend to be steeped in patriarchy, with low female literacy rates and a high incidence of child marriage.It is a vicious cycle: women are anemic, malnourished, uneducated, disempowered, physically weak because of annual pregnancies, and poor. And they do not use family planning methods even when they are available at rural health posts.Read also:<a style="background-color: #ffffff; font-size: 15px; letter-spacing: 0.01em;" href="https://www.nepalitimes.com/opinion/miracle-drug-to-reduce-maternal-deaths/" target="_blank" rel="noopener">Miracle drug to reduce maternal deaths</a>, Buddha Basnyat<a href="https://www.nepalitimes.com/here-now/who-will-save-nepals-poor-new-mothers/" target="_blank" rel="noopener">Who will save Nepal’s poor pregnant women … a government plan, or God?</a>, Rojita Adhikari<a href="http://archive.nepalitimes.com/blogs/thebrief/2011/09/22/nepals-work-in-maternal-health-noticed/" target="_blank" rel="noopener">Global recognition for Nepal’s maternal health program</a>, Nepali TimesIn these villages in the mountains of Bajura, Achham and Baitadi there are many families where a mother and her daughter are giving birth simultaneously. The region’s medical services are also basic, which means a low incidence of institutional delivery and a maternal mortality rate that remains more than twice the national average.The government offers five types of contraception for free in health posts: condoms, pills, injectables, implants and intrauterine contraceptive devices (IUCDs). However, belief that contraceptives affect health or the unavailability of the desired device means many do not opt for family planning.“Every day an average of five women come to our health post to ask about long-acting contraceptives like IUCDs or implants, but we either do not have the devices or the trained health workers to insert them,” shrugs Sabina Thapa, a nurse at a Bajura health post. “Even women on pills miss the timeline and get pregnant.”Read also: <a href="https://www.nepalitimes.com/here-now/nepal-far-from-hitting-contraceptive-target/" target="_blank" rel="noopener">Nepal far from hitting contraceptive target</a>, Sewa Bhattarai<a href="http://archive.nepalitimes.com/news.php?id=14551#.Xk6ENzIzbIU" target="_blank" rel="noopener">Treating pain and shame</a>, Mallika AryalCurrently, 43% of all married women of reproductive age in Nepal use modern contraceptives, and another 10 % use traditional family planning methods. A 2016 survey showed that there is a 44% unmet need for family planning measures in Nepal.A recent report by the <a href="https://www.guttmacher.org/fact-sheet/adding-it-up-meeting-contraceptive-mnh-needs-nepal" target="_blank" rel="noopener">Guttmacher Institute</a> showed that Nepali women have 1.2 million pregnancies each year, of which 539,000 are unintended. Nearly a quarter of these result in unplanned births and two-thirds are aborted.“Actually, we have achieved a lot with the little money we have invested,” explains Bhim Singh Tinkari of the Family Welfare Division in Kathmandu. “But the money is mainly to buy contraception and family planning products. There is a huge gap in contraceptive supply, public awareness and trained health workers.”“If all unmet need for modern contraception were met, unintended pregnancies would be reduced by 87%, or 469,000 annually, and unplanned births, abortions and miscarriages would decline by the same proportion. Fully meeting women’s need for contraception would reduce maternal deaths,” The Guttmacher Institute report concludes.To address the unmet need would cost only $30million according to a survey, but this is five times more than the government’s current family-planning budget. Without this funding Nepal is unlikely to meet the Sustainable Development Goals (SDG) target of 75% contraceptive prevalence.“The situation has become more complicated than before with the new federal system. Local health needs are now the responsibility of provincial and municipality governments, but work has not started yet,” says Tinkari. “We need the money and we need to act soon if we are to meet the 2030 target.”<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109101136/636b75319c7e80680e0623d8jpeg.jpg" alt="" width="1500" height="1000"/><figcaption>Kewara Koli, 34, is already mother to seven daughters and one son. Her eldest daughter, Laxmi, is in Grade 10 at a local school in Baitadi. Laxmi advised her mother to get an implant from a nearby health post. “My mother was giving birth every two years, and she became weaker after every baby,” says Laxmi (standing at back).</figcaption></figure><figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109101136/636b75349c7e80680e0623d9jpeg.jpg" alt="" width="1500" height="1000"><figcaption> </figcaption></figure><figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109101136/636b75379c7e80680e0623dajpeg.jpg" alt="" width="1500" height="1000"><figcaption> </figcaption></figure><figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109101136/636b753b9c7e80680e0623dbjpeg.jpg" alt="" width="1500" height="1000"><figcaption> </figcaption></figure><figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109101136/636b753e9c7e80680e0623dcjpeg.jpg" alt="" width="1500" height="1000"><figcaption> </figcaption></figure>Read also: <a href="https://archive.nepalitimes.com/article/Nepali-Times-Buzz/globe-rallies-to-aid-nepals-women,3841" target="_blank" rel="noopener">Cutting the lifeline</a>, Kate Ryan<a href="http://archive.nepalitimes.com/article/nation/people-politics-placentas-child-delivery-complications,3922" target="_blank" rel="noopener">People, Politics, and Placentas</a>, Bikash Gauchan

maternal-health