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

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No conceivable reason for unwanted pregnancies

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109101120/636b70d49c7e80680e06009bjpeg.jpg" alt="" width="1500" height="803"/><figcaption>Photo : UNICEF</figcaption></figure>Last month, the prestigious <a href="https://www.nejm.org/" target="_blank" rel="noopener">New England Journal of Medicine</a> published a study of the <a href="https://www.nejm.org/doi/full/10.1056/NEJMoa1905047" target="_blank" rel="noopener">successful trial of a new typhoid vaccine</a> that could prevent thedeaths of many children around the world. The vaccine research was conducted at Patan Hospital by a Nepali researcher.The randomised control trial of the typhoid conjugate vaccine (TCV) was conducted among more than 20,000 participants in Lalitpur district, and the efficacy of the new vaccine was found to be 81.6% -- a major improvement on previous vaccines. (See box below).The positive news from Nepal came as various parts of the world, including the US, Europe, Samoa and Africa, struggled to cope with the biggest measles outbreak in decades. Most of the cases have now been associated with people forgoing recommended preventive shots because of fears of side-effects fanned by social media.Fear of vaccination started ever since a paper in 1998 in the medical journal <a href="https://www.thelancet.com/" target="_blank" rel="noopener">The Lancet</a> cited a link between autism and the <a href="https://archive.nepalitimes.com/article/Nepali-Times-Buzz/maurice-hilleman-the-vaccine-man,1852" target="_blank" rel="noopener">measles, mumps, rubella (MMR) vaccine</a>. The research was later found to be fraudulent and retracted, but the anti-vaccine movement gained traction again in the past year after the rumours resurfaced on the Internet resulting in families rejecting early childhood immunisation against diseases like polio, rubella and measles.“The good news is that unlike in the rest of the world, people in Nepal demand vaccines. If we miss to vaccinate a child for any reason, parents come knocking, asking for the shots,” says Jhalak Gautam of the Family Welfare Division at Teku.Sameer Mani Dixit of The Centre for Molecular Dynamics Nepal concurs. “Entire communities actively participate in vaccination programs and are well aware of the benefits. Every mother in Nepal knows the immunisation schedule by heart.”The Centre for Molecular Dynamics Nepal has just completed a study on why the country has been so successful with its immunisation program, and the results will be published later this month. This study and similar studies underway in Senegal and Zambia are being conducted with  funding from the Bill and Melinda Gates Foundation, in an effort to analyse the success of vaccination programs in developing nations.Nepal’s national immunisation program started in 1988 and now vaccinates some 620,000 children under 15 months of age every year against 11 infectious diseases such as <a href="https://www.nepalitimes.com/banner/tb/">tuberculosis</a>, <a href="https://archive.nepalitimes.com/article/Nepali-Times-Buzz/Bouncing-back-higher-wheelchair-basketball,3802" target="_blank" rel="noopener">polio</a>, pneumonia and measles.The last case of <a href="https://www.nepalitimes.com/banner/polio-hunt/" target="_blank" rel="noopener">polio</a> was detected in Rautahat district in 2010, and Nepal was declared polio free four years later. The country also eliminated maternal and neonatal tetanus in 2005. Similarly, Japanese encephalitis, diphtheria, pertussis and pneumonia have all been controlled, and there are regular vaccinations against congenital rubella syndrome and hepatitis B.Despite the high immunisation rate, thousands of Nepali children continue to die due to easily preventable and treatable communicable diseases <a href="https://archive.nepalitimes.com/news.php?id=16988#.XiBL7_4zaUk" target="_blank" rel="noopener">like diarrhoea</a> and according to Nepal Demographic Health Survey 2016, one in a hundred Nepali children have still not been vaccinated against any infectious diseases.Read also: <a href="https://www.nepalitimes.com/here-now/nepal-is-a-microcosm-of-all-of-the-changes-in-world-health/" target="_blank" rel="noopener">"Nepal is a microcosm of all the change in world health"</a>Immunisation coverage data from last year also shows a worryingly high dropout rate. While 93% of newborns received BCG jabs, the first in the national immunisation schedule, the coverage dropped to 73% by the time children received the last vaccine, an immunisation against measles and rubella, recommended at the age of 15 months.Several cases of <a href="http://archive.nepalitimes.com/news.php?id=186#.XiBGW_4zaUk" target="_blank" rel="noopener">measles</a> have been detected in Kapilvastu, Dang, Makwanpur, Sarlahi and Manang districts recently, and Nepal has not been able to meet its previously set target to eliminate measles and rubella by 2019. The new goal is to eliminate the diseases by 2023.“Dropout rate is a challenge, we have not been able to reach the remotest corners of the country, and children miss their shots because of migration,” says Jhalak Gautam. “We now have a strategy to identify missed pockets and deliver shots at home if required.”The Immunisation Section of the Ministry of Health is now gearing up for a nation-wide measles-rubella vaccination campaign aimed at those who might have missed routine shots. Three million children between the ages 9 months to 5 years are expected to participate in two phases of the campaign later this year.Polio drops will also be administered at the same time to 1.5 million children under five in 19 Tarai districts. The Immunisation Section is also introducing a new vaccine against rotavirus this June to reduce the prevalence of childhood diarrhoea.The new challenge to vaccination comes from an unlikely quarter: federalism. There is confusion about where the vaccines are sourced and who should pay for them. There is concern about the quality of vaccines, many of which need a cold chain with refrigeration to the point of delivery.Warns Patan Hospital physician Buddha Basnyat: “Nepal’s immunisation program is a model of success, but we cannot afford to be complacent.We have to introduce newer and more effective vaccines while also prioritising hygiene and <a href="https://www.nepalitimes.com/banner/toilet-trained/" target="_blank" rel="noopener">sanitation</a> simultaneously.”<h2>Successful trial of new typhoid vaccine</h2><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109101120/636b70d79c7e80680e06009cjpeg.jpg" alt="" width="1500" height="1000">Over 20,000 children between 9 months and 16 years of age in Lalitpur district participated in the <a href="https://www.nejm.org/doi/full/10.1056/NEJMoa1905047" target="_blank" rel="noopener">first large-scale randomised controlled trial</a> of a new vaccine against <a href="http://archive.nepalitimes.com/news.php?id=17306#.XiBGav4zaUk" target="_blank" rel="noopener">typhoid</a>, a disease that affects millions across South Asia.Half of them received the vaccine and the other half received control shots. The efficacy of Typhoid Conjugate Vaccine (TCV) was found to be 81.6%, and the results were published last month in the prestigious New England Journal of Medicine.Prior to this, a small-scale TCV trial was conducted in Britain, and the World Health Organisation (WHO) has since strongly recommend the use of the vaccine for countries and regions where the water and food-borne infection is most common. "Pakistan has been able to control typhoid with this vaccine and <a href="https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(19)30320-1/fulltext" target="_blank" rel="noopener">Vietnam</a> has eliminated it," says lead author of the paper, Mila Shakya, "Administration of this new, effective vaccine by our government will help control the most common bacterial disease in Nepal and South Asia."<a href="http://archive.nepalitimes.com/news.php?id=12158#.XiBGbP4zaUk" target="_blank" rel="noopener">Typhoid</a> is a contagious infection caused by the bacteria Salmonella typhi, which is found in contaminated food and water and which causes fever, diarrhoea and vomiting. It can easily be prevented with awareness, safe drinking water and frequent hand-washing.The vaccine is useful because it is a prophylactic in places where preventive measures are taking time to implement. There are some 21 million typhoid cases and 161,000 typhoid-related deaths annually worldwide. South Asia has been often dubbed as the hub of typhoid and there are some 500 cases per 100,000 population in the region.“This study is Nepal taking a lead in preventing typhoid, after never having really prioritised it. It might not kill as many people as other diseases do, but it still affects thousands of school-going children,” says physician Buddha Basnyat at Patan Hospital.TCV is <a href="http://archive.nepalitimes.com/news.php?id=18178#.XiBGdP4zaUk" target="_blank" rel="noopener">not the first typhoid vaccine to be developed</a>. Currently there is an injectable unconjugated polysaccharide vaccine for persons aged two years and above, and an oral capsule for those over six years of age. But they do not work well on young children and they provide protection only for a few years. TCV on the other hand can be given to children below 2 years and the immunisation lasts up to five years.“A single dose of the new vaccine is safe, immunogenic, and effective, and the deployment of the vaccine will reduce the burden of <a href="https://www.nepalitimes.com/opinion/so-far-so-good/infectious-enthusiasm-for-travel/" target="_blank" rel="noopener">typhoid</a> in high-risk populations,” stated the interim analysis. “This new evidence of efficacy is especially timely with the recent spread of extensively drug resistant typhoid fever, which threatens child health in affected regions.”Pakistan, which has been struggling against an outbreak of drug resistant typhoid fever since 2016 is already using TCV with positive results and its Sindh province will become the first region in the world to include TCV in routine childhood immunisations.<a href="https://www.gavi.org/" target="_blank" rel="noopener">Gavi, the Vaccine Alliance</a>, which has earmarked $85 million to fund the introduction of the vaccine in the world’s poorest countries, is supporting the program. Nepal is also eligible for funding from the alliance.Says Basnyat: “We should take action before we are also hit, like Pakistan, by the drug-resistant typhoid. What are we waiting for, when Gavi is ready to fund the vaccination program for free and its benefits are so clear. This is a case of vaccine under-utilisation.”Sonia Awale

Sonia Awale

A shot in the arm for vaccines in Nepal

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221108151124/636a66fa9c7e80680e0599b4jpeg.jpg" alt="" width="1500" height="1081"/><figcaption>Photo : BIKRAM RAI</figcaption></figure>Nepal is recognised as the only low-income country to have made rapid progress cutting poverty and boosting public health and education in recent decades. But can these achievements be sustained in the 2020-2030 decade?The <a href="https://archive.nepalitimes.com/regular-columns/GUEST-COLUMN/Saving-one-mother-at-a-time,816" target="_blank" rel="noopener">country’s maternal mortality rate decreased</a> from 539 deaths per 100,000 live births to 239 deaths between 1996 and 2016. The adult literacy rate rose from 20% in the 1980s to 67% in 2018, and the proportion of Nepalis living below the poverty line <a href="https://www.nepalitimes.com/banner/nepals-great-income-divide/" target="_blank" rel="noopener">dropped from 42% to 21% in two decades</a>.Yet the poorest still <a href="https://www.nepalitimes.com/banner/federalism-leaves-nepals-medical-sector-ailing/" target="_blank" rel="noopener">do not have access to affordable healthcare</a>. The school dropout rate is as high as the <a href="http://archive.nepalitimes.com/news.php?id=41#.XftNv5MzaUk" target="_blank" rel="noopener">enrolment rate</a>. In urban centres, people breathe <a href="https://www.nepalitimes.com/here-now/air-pollution-is-more-dangerous-than-smoking/" target="_blank" rel="noopener">some of the foulest air in the world</a>, reducing their life expectancy by up to four years. Many lack safe drinking water.Read also: <a href="https://www.nepalitimes.com/?p=38023&amp;preview_nonce=024823c344&amp;preview=true" target="_blank" rel="noopener">Towards 2030</a><a style="background-color: #ffffff; font-size: 15px; letter-spacing: 0.01em;" href="https://www.nepalitimes.com/?p=38038&amp;preview_nonce=e8166bf726&amp;preview=true" target="_blank" rel="noopener">Another decade to get it right,</a> Editorial<a style="background-color: #ffffff; font-size: 15px; letter-spacing: 0.01em;" href="https://www.nepalitimes.com/?p=38061&amp;preview_nonce=012fb23553&amp;preview=true" target="_blank" rel="noopener">Nepal in the 2020s,</a> Sewa BhattaraiLocal elections in 2017, after a gap of 20 years, were supposed to close these gaps by delivering accountable, elected leaders. Two years later, the euphoria has evaporated. The state of the state remains stagnant.“The elections helped us rebuild grassroots democracy and decentralise power, but the lack of accountability at all levels of government continues to be a major challenge,” says Min Bahadur Shahi of the National Planning Commission (NPC). “This is why the primary agenda of the NPC’s 15th periodic plan is governance reform, controlling corruption and promoting transparency.”As we step into the new decade, there are questions about Nepal’s progress in human development, including whether we are on track to meet the UN’s Sustainable Development Goals (SDGs) and achieve double-digit growth. Reaching these targets will require huge investments in healthcare, schools and nutrition. With the <a href="https://www.nepalitimes.com/editorial/poor-health-makes-nepalis-poorer/" target="_blank" rel="noopener">emergence of non-communicable diseases</a>, Nepal now faces a double burden: rising rates of <a href="https://archive.nepalitimes.com/article/nation/diabetes-in-south-asia,3018" target="_blank" rel="noopener">diabetes</a>, cardiovascular diseases and cancer, which are expensive to treat, while the poor continue to die of easily curable infections.Said Sanjib Sharma, doctor at the BP Koirala Institute for Health Sciences in Dharan: “Our efforts now should be on strengthening primary health care and prevention and early detection of diseases using existing tools, as well as new technologies such as artificial intelligence for virtual expert consultation and drug delivery.”Read also: <a style="background-color: #ffffff; font-size: 15px; letter-spacing: 0.01em;" href="https://www.nepalitimes.com/?p=38051&amp;preview_nonce=38f8426e6c&amp;preview=true" target="_blank" rel="noopener">Nepal in 2030,</a> Sanghamitra Subba<a style="background-color: #ffffff; font-size: 15px; letter-spacing: 0.01em;" href="https://www.nepalitimes.com/?p=38046&amp;preview_nonce=d2d7129548&amp;preview=true" target="_blank" rel="noopener">A future written in the stars,</a> Sanghamitra SubbaDespite poverty falling by half, one-third of Nepali children <a href="https://www.nepalitimes.com/banner/nearly-half-of-nepali-children-still-malnourished/" target="_blank" rel="noopener">are still malnourished</a>. Anaemia among women has actually increased in recent years. The government’s Multi-sectoral Nutrition Plan, developed in 2012, works to improve maternal and child health, vaccination rates and malnutrition.“Development in Nepal is still synonymous with roads, but investing in early childhood development is equally important, it is a component of development,” said Kiran Rupakheti of the NPC, which wants nutrition programs to reach the grassroots.Even as literacy rates rise, gender disparity is expected to continue in the coming decade. As female literacy improves, for instance, <a href="https://www.nepalitimes.com/banner/child-marriage-in-nepal-eloped-at-13-mother-by-17/" target="_blank" rel="noopener">child marriage</a> and <a href="http://archive.nepalitimes.com/news.php?id=19596#.XftPh5MzaUk" target="_blank" rel="noopener">girls’ dropout rates</a> will persist. Experts say improving the <a href="https://www.nepalitimes.com/banner/after-quantity-nepals-education-needs-quality/" target="_blank" rel="noopener">quality of instruction</a> at community schools, encouraging female students in technical fields and promoting applied education should be priority areas in the 10 years ahead.Nepal is expected to graduate from lower-middle-income country status by 2030, but that is unlikely if the SDGs goals are not met. For this, the government will need to spend $1billion a year in infrastructure alone. Nepal is hoping to sustain <a href="http://archive.nepalitimes.com/regular-columns/guest-editorial/guest-editorial-Nepal-economic-growth,923" target="_blank" rel="noopener">double-digit growth</a> of above 10% and achieve per capita income of $1,595 by the end of the decade.“I’m hopeful about our prospects but if we uplift the economic status of women, who make up more than half of the population, we will get there sooner,” said Saru Joshi, gender and development expert.<a href="http://archive.nepalitimes.com/blogs/thebrief/2017/05/24/bleak-economic-report/" target="_blank" rel="noopener">A 2017 World Bank report</a>, however, stated that if present trends continue Nepal will not reach its middle-income target. It pointed out that despite rapid reduction in the poverty rate, the country’s development path has not led to economic growth but perpetuated a shortage of jobs at home, which in turn is fuelling further <a href="https://www.nepalitimes.com/editorial/reducing-labour-pain/" target="_blank" rel="noopener">outmigration</a>. And while remittance accounts for one-third of the national GDP, it is a symptom of deep-seated, chronic problems.Planners say that a slew of new hydropower and large infrastructure projects planned for the next 10 years, a boom in <a href="https://www.nepalitimes.com/opinion/guiding-nepals-tourism-industry/" target="_blank" rel="noopener">tourism and the service sector</a>, and better connectivity will create jobs at home, discouraging youth from seeking employment elsewhere.“We know our targets are ambitious but we also have the most favourable environment to achieve it. There is finally stability, the present growth is already at 7%, some <a href="https://www.nepalitimes.com/opinion/decentralising-hydropower/" target="_blank" rel="noopener">major hydropower projects</a> are taking off and we have made huge investments in information technology,” said Rupakheti.Shahi forecasts optimistically: “The 2020s will be a progressive decade of sustainable and just development. There will be prosperity along with social justice. There will be double-digit growth, increased investment from the government and the focus will be on quality, not quantity.”

How will Nepal develop in the next decade?

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No conceivable reason for unwanted pregnancies

A shot in the arm for vaccines in Nepal

How will Nepal develop in the next decade?