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Confidential: For Review OnlyFactors associated with neonatal deaths and childhood

morbidity in the Dolpa district, Province 7, Nepal Guenter Kittel1, Bindu Karki2

Author affiliations: 1 University of Vienna

2 Charité University, Berlin Correspondence to

Dr. Guenter Kittel, Ausstellungsgasse 3a/409, 2700 Wr. Neustadt, AUSTRIA, [email protected];

+436764670759 Neonatal mortality, Child morbidity, poverty

Word count: 3400

Journal: BMJ Paediatrics Open

Manuscript ID bmjpo-2019-000519

Article Type: Original article

Date Submitted by the Author: 09-May-2019

Complete List of Authors: Kittel, Guenter ; University of ViennaKarki, Bindu ; Charite Medical Faculty Berlin

Keywords: Health Service, Mortality, Neonatology, Tropical Paediatrics

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Confidential: For Review Only

Factors associated with neonatal deaths and childhood morbidity in the Dolpa district, Province 7, Nepal

1

Factors associated with neonatal deaths and childhood morbidity in the

Dolpa district, Province 7, Nepal

Guenter Kittel¹, Bindu Karki²

Authors Affiliations:1; University of Vienna2; Charité University, Berlin

Correspondence toDr Guenter Kittel, [email protected]

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Abstract

Introduction

Overall Nepal has made significant progress in improving women’s and children’s health. The

national under 5 child mortality rate decreased from 162 /1000 in 1991 to 54/1000 in 2011

and maternal mortality reduced from 850 to 170/100,000 during the same period. However,

the neonatal mortality rate (NMR) has remained stagnant at around 30 deaths per 1000 live

births (LB), accounting for 61% of child mortality in 2011. As in most countries the main

progress has been in cities and urban centres, with less progress in the remote districts.

Methodology

A quantitative (retrospective cross-sectional) study evaluating neonatal deaths and childhood

morbidity, and a qualitative study (semi-structured interview) in 10 remote villages in Dolpa

district in the north-west of Nepal about the cultural perception of neonatal death and

morbidity.

Results

In Dolpa district, neonatal mortality rate was estimated as 67 per 1000 live births and under 5

mortality of 100 per 1000.

Key-words

Nepal, neonatal mortality, child mortality and morbidity, remote districts, rural communities,

lack of access, poverty

Key-messages

There is substantial under-reporting of neonatal mortality in the region

Most deliveries are home deliveries

There is a chance for adequate improvements

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Introduction and background

The specific context of Nepal

Nepal is one of the least developed and poorest countries in Asia (1). Many Nepalese continue

to live a traditional life. Religion is of uttermost importance. About 80 per cent of the

population are Hindus and adhere to caste system, about 10 per cent are Buddhists, mainly

living in mountainous regions like Dolpa.

Many parts of the country had been almost impossible to access until 60 years ago and

modernisation has still not reached many areas. ‘Purity’ and traditional lifestyle are of high

values, and for the majority of the population, a struggle for daily survival is the reality of life.

Innovations may be observed with interest but changes and adaptations are not the strength of

a conservative society (2). Those statements are valid for Nepal as whole but particularly for

the Buddhist dominated region of Dolpa. Nepal opened its borders as late as the 1950s, and

many areas still have a restricted access.

Dolpa is a remote district in Western Nepal. It is highly mountainous with an altitude between

2500 and 4500 meters above sea-level, and is one of the highest populated locations on earth.

The Dolpa area covers roughly 10,000 km² and the population is about 35,000 people. There

is no road network and most parts of the area can be only accessed when crossing passes

above 5000 meters. The district borders Tibet on the North, Jumla and Mugu districts on the

West, Myagdi, Jajarkot and Rukum on the South and Mustang on the East. Dolpa is

influenced culturally by Tibetan Buddhism. The Tibetans mainly live north of the district

capital, Dunai, in scattered smaller villages. Around Dunai there are some relatively large

Hindu Chetri and Brahmin villages, representing about 40-45% of the population. There are

also a few Magar and Gurung villages. The people of Dolpa still live a traditional life-style,

based on subsistence economy and trade.

The problem

Nepal has made a significant improvement reducing the child mortality rate (3). In less than

25 years child-mortality has decreased from 162 deaths per 1000 live births in 1991 to 54 in

2011 according to national data. Nepal has successfully improved coverage of effective

interventions to prevent or treat the most important causes of child-mortality through a variety

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of community-based approaches and national campaigns. These approaches have included

high coverage of 6 monthly vitamin A supplementation and deworming, the integrated

management of childhood illness (IMCI), high national immunization coverage, and moderate

coverage of exclusive breastfeeding of children under 6 months (4,5).

However, access to health care and to community based child health interventions varies. The

northern part of Nepal remains isolated and in many parts there are no road connections to

district hospitals and main health centres. Often several days of walking are needed to reach

these health care facilities. In this situation most deliveries take place at home in traditional

ways.

According to the 'Nepal Demographic and Health Survey 2016' (6) the overall figures

regarding maternal health, the nutritional status of children and attendance at health centres is

lowest in State 6, Karnali province. It is quite likely that there is under-reporting of still-birth,

neonatal death and child mortality (7).

The main reason for childhood morbidity and mortality are prematurity, intra-partum related

complications, respiratory tract infections, diarrhoeal diseases and injuries. (8).

Rationale

We designed this study to understand the health status of children in Dolpa district. We

aimed to have quantitative estimations about children's health outcomes, and qualitative

information on possible cultural reasons for current neonatal care to understand the challenges

to fulfilling Nepal’s ‘Every Newborn Action Plan’ (4).

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Methodology

Ten villages (clusters) were randomly selected. The selection included villages with different

ethnic groups (9), two bigger villages mainly inhabited by Chetri, one mainly inhabited by

Magar, the district headquarter Dunai with a mixed population and six other villages, five

inhabited by Tibetans and one by Gurung (10).

The 10 villages included in the study had a total population of about 12,000 out of the total

Dolpa population of 35,000 people (Statistics, 2014), and the villages are representative of the

geographical and ethnic distribution of the area.

Patient and public involvement

After discussions with the village leader and the village elders households were randomly

visited and after having received the consent of at least one of the parents, children under the

age of 5 were enrolled in the study.

1. Childhood morbidity. 100 children were investigated (10 in each village) for malnutrition,

and if they had acute lower respiratory infection (ALRI), acute watery diarrhoea or any

other disease in the previous month, including currently. The selection was done by single

stage random sampling. Written consent was taken from the parents. The sample size was

based on an expected prevalence of the presence of a disease of 20% and at a confidence

level of 90%. We asked the parents if the child had or had had during the last month an

ARI, watery diarrhoea, fever of any other cause or an injury.

2. Neonatal and under-5 mortality.The total population of the villages under investigation

was about 12000 with a total of about 300 deliveries per year. The expected prevalence of

neonatal mortality was 50/1000 and of the under-5-mortality was about 75/1000. We

asked health staff and officials about the number of deliveries, the number of neonatal

deaths and the number of children who have died during the last year. As the villages are

rather small, as the members of the community have a good social network and as the

numbers were consistent, the numbers are likely realistic.

3. Cultural perceptions of newborn and child health. Consenting parents were involved in a

semi-structured interview about neonatal deaths, their views on child health, the problems

they faced and the actions they are and have been taking. We used by a semi-structured

interview to understand: how the death of a newborn is perceived by the family; whether

common childhood diseases are treated or prevented using local remedies; what solutions

the community may propose to improve the child and newborn health status. One to three

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interviews were taken in each of 10 villages, a total of 20 interviews. Qualitative

interviews were conducted in Nepali or Tibetan by the accompanying health assistant and

then immediately transcribed in English. All interviews were done in a private

environment respecting the dignity of the participants and with their full consent.

The results will be disseminated to the district authorities with the aim to improve

interventions.

Statistical analyses

Quantitative data on neonatal deaths and child morbidity were analysed with EpiInfo 7

software and Excel.

Ethics

Ethical clearance permission was granted by the Nepal Health Research Council. The

guidelines were strictly followed.

Results

Childhood Morbidity

Parents of eleven out of 100 children surveyed reported an acute lower respiratory infection

during the previous month. There was general agreement by parents and health workers that

pneumonia is the main problem for childhood morbidity.

Parents of 7 children out of 100 reported their child suffering from acute watery diarrhoea

during the previous month. Diarrhoea was more common in the Chetri (5 cases) than in the

Tibetan population (2 cases). In 4 cases there was a combination of malnourishment and

diarrhoea and all those combined cases had occurred in Chetri villages.

Due to lack of other facilities we used MUAC (mid upper arm circumference) as a diagnostic

tool for protein-energy malnutrition. Eight children had malnutrition; in 4 cases there was a

combination of malnourishment with diarrhoea, in 1 case a combination of pneumonia and

malnourishment at the time of investigation. All cases of malnourishment were seen in the

Chetri villages; in the Tibetan villages no malnutrition was diagnosed.

One child suffering from malnutrition and ARI had congenital heart disease. No other disease

was diagnosed for the children under investigation.

Contrary to expectation injuries including burns obviously did not play a major role for the

childhood morbidity in Dolpa district.

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Neonatal and childhood mortality

According to our investigation there were about 300 deliveries in the investigated villages

(population of around 12500) during last year and 20 neonatal deaths were reported. This

reflects a neonatal mortality rate of 67/1000 (95% confidence interval 41-101/1000).

The highest neonatal mortality rate appeared to be in Chetri villages in the southern part of

Dolpa. There was general agreement that most deliveries take place at home without trained

birth attendant and that neonatal deaths are usually not reported. Reasons for most of the

neonatal death could not be given.

10 children older than 28 days had died during last year, 5 were suffering from pneumonia, 5

were suffering from bloody diarrhoea. The under-5-mortality rate for the area of study was

found to be 100 per 1000 live births.

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Interviews

20 village members, 1-3 in each of the 10 villages, were asked about their perception of

neonatal death and about any sickness of their children as well as their approach for a

solution.

How the death of a new-born is perceived by the family: families generally agreed that the

death of a new-born is a natural event which has to be accepted. The reason behind are karma

(destiny) and that it is God’s will. It has been also not considered as a major blow of fate as

usually there is still the possibility of having more children. It is not considered as reason to

look for better ante-natal care.

Ditya tells:

‘I have been married at a very young age and had twice a female baby who died

immediately after birth. Yes, I have been very sad, but I did not really worry. I was

told that it is a common occurrence and it is the will of God. So I was looking forward

to get pregnant again. Now I have three children and they are all healthy and strong.’

Sabitri teels:

‘My marriage took place when I was only 14 years old. Only few years later I got

pregnant for the first time. I do not know how old I have been then. After a baby girl

was born I had to stay for 9 days at home. It was winter and was very cold. The baby

got sick shortly after delivery. I was thinking to go to a doctor but I was told that the

cause of the fever is Bhut (bad spirit, evil eye) and whatever happens would be God’s

will. After two weeks the baby died. Fortunately a year later I got pregnant again and

gave birth to a healthy son. My family was very happy.’

Dolma tells:

‘For a long time I did not get pregnant. My first baby was very weak and got sick

immediately after delivery, which took place at my home. It died a few days later. I

knew I would get pregnant again so I was not too unhappy. 18 months later I gave

birth to a healthy boy. Now I have two boys, they are fine.’

How the main childhood diseases like ARI’s and diarrhoeal diseases are prevented by local

remedies: most families try to get modern medicine like antibiotics in case of any disease of

their children.

Hara tells:

‘My son was coughing a lot. He did not eat properly and had high fever for several

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days. I asked our village leader if he has some medicine from foreigners. He gave me a

few tablets. I smashed those pills and gave it to my son with hot water. He still

continued to have fever and cough for a couple of days. But then he improved.’

Yangchen tells:

‘My daughter had diarrhoea for a couple of days. I also noticed that she there was

blood in her stool. She was very sick and lost a lot of weight. I was very worried that

she would die. So I went to the next health post. The nurse gave me medicine, but it

still did not improve. Then I looked for our Amchi (doctor practising traditional

medicine). He took very well care of my daughter and finally after weeks she

recovered. Now she is a strong young girl.’

Goma tells:

‘When my son was about 2 years old he had repeated attacks of diarrhoea. He started

to lose weight. After one to two months I thought he might die. We went to our health

post but the health worker was not present. So we performed a ceremony (Chakri) at

our home. A few days later my son recovered and since then he hardly got sick

anymore.’

Which solutions the community is proposing as prevention: the 3 women interviewed in the

district capital Dunai were satisfied with the service of the district hospital. They said that

most of the time nurses are present and are providing a proper service to the patients.

2 women living close to Tapriza also appreciated the service provided by the health post

there.

The other 15 women, living in villages with far distance to a health post or experiencing the

constant absence of staff all expressed the wish for a health post with permanent staffing. The

answers were all similar.

The following reply in Dho Tarap, a Tibetan village.

‘We find it useless to go to a health post. Most of the time there is no health worker anyway

and if we find him he does not have medicine. If our children are sick we have to fly to

Kathmandu. But that is very expensive and most of us cannot afford that. So usually we ask

our friends if they have at home some medicine which they might have taken with them

during the last visit to the capital or we hope that some tourists give us some western

medicine. All of us wish that we would have a health post with a permanent staff, who are

able to give us medicine.’

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The general perception has been that medical help is only possible in the main towns of Nepal

like Kathmandu or Pokhara.

We saw health posts without staff present, or if the staff was present there was no medicine.

Some were posts were lacking water, and even the district hospital had no warm water supply.

On the other hand we found a couple of dedicated nurses, so the judgements of some

interviewed mothers might be also based on some misconceptions, like medicine from tourists

is ‘good medicine’, even without having any idea about indication or dosage. To go for

medical treatment to Kathmandu seemed to be also a question of the social status and the

dedication of local nurses and the importance of medical knowledge and proper clinical

examination have been generally underestimated and the possibilities in the capital with CT

and other expensive procedures highly overestimated.

Quite often people went for medicine to a health post but at the same time they also tried local

remedies to find a cure, mainly by performing ceremonies.

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Discussion

Childhood Morbidity

Childhood morbidity in Dolpa has been relatively low in comparison to the Nepal average

(11–14). Respiratory infections were common in the colder regions inhabited by mainly

Tibetans whereas diarrhoea has been more common in the lower regions mainly inhabited by

Chetris.

Malnourished children were only found in two villages, both of them Chetri villages,

Tripurakot and Raha, whereas in the other villages malnourishment has not been a problem.

Although the economic situation has not been part of the study it appears to be highly likely

that the level of income is playing an important role. The Tibetan villages are economically

better off than the Chetri communities. Reasons are the generating of income by the sale of

Yartsa Gunbu or Cordyceps Sinensis (15), by trade with China and the fast growing tourism

industry.

There is one district hospital in Dunai where one doctor and several nurses are doing their

service. In some villages health facilities (buildings) were present, but no staff was available.

We were told that this problem exists for most time of the year. Still vaccinations campaigns

are taking place and as people are aware of the advantage of vaccinations there seems to be a

high coverage rate.

Most households had some antibiotics available, either collected during a stay in Kathmandu

or given by tourists. The medicine is usually given without proper knowledge of dosage or

indication. (Table 1)

Table 1

Type of sickness


Previous studies in Nepal have shown considerable disparities in neonatal, infant and under 5

mortality. Studies in the Mugu District (a neighbouring district to Dolpa) in 2000 have

reported an infant mortality rate as high as 201/1000 (16).

In our study there has been general agreement by parents and health staff that many neonatal

deaths are not reported. Deliveries are usually taking place at home and attended by an

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‘experienced’ family member like the mother or an aunt or a person who is considered to be

skilled.

We did not hear of maternal deaths during the last year, though it was reported that there have

been some in previous years. In some cases and if finances are allowing some pregnant

mothers are going to Kathmandu for delivery.

According to our findings the number of neonatal deaths is 67/1000 and so double as high as

the present average figures for Nepal (17). A previous report of infant mortality in a

neighbouring district of Mugu was even 201/1000 (16).

The main reasons for an improvement appear to be successful vaccination campaigns and

economic progress in some regions. On the other hand there is obvious lack of ante- and

postnatal care, home deliveries without the presence of skilled birth attendants are still taking

place in the majority of cases and there is lack of hygienic conditions as warm water is hardly

available. (Table 2)

Table 2

Mortality rates

Cultural perceptions

In the qualitative part we were confronted with several well-known traditions.

In the Chetri villages girls are married at an early age, some of them at the age of 14 and in

few cases even below that age. The first pregnancy is taking place as a consequence mostly

before having reached the age of 20. Birth and the neonatal period are always strongly

connected with supernatural beliefs. For the first days after delivery the neo-nates should not

leave the room, they are supposed not be exposed to sunlight, otherwise bad spirits will get

power over them. Early breastfeeding is also rather discouraged as the colostrum is

considered to be dirty. In spite of repeated campaigns encouraging breastfeeding traditional

conceptions continue to be influential.

Still people were very open and were hoping for improvements. They have been grateful for

health services provided and expressed their wish for a permanent service. Although fatalism

has been often addressed as a key factor for non-reporting neonatal deaths as well as for non-

accepting changes, an approach for a more active community participation through

strengthening of health promotion could lead to positive results (7). There is surely readiness

and hope from the side of the community.

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Limitations

Major difficulties for the collection of data were the lack of health facilities, if health facilities

were present there was lack of health staff, and overall there was lack of records. The

interviewed health workers generally agreed that most children are not taken to a health

facility if sick and due to the high number of home deliveries cases of neonatal death are

usually not reported. Another problem was the definition of ARI. Regarding ARI we had to

confine to the definition of cough and fever, the assessment for fast breathing has been vague.

So we were mostly dependent on information from parents or village elders.

Because of the small scale of the study it has not been possible to get exact data about the

average age for the first delivery, the spacing, the educational level and the economic status,

but it was obvious that there is a difference between the mainly by Chetri populated villages

in the south of Dolpa and the Tibetan villages in the north. The acceptance of family planning

and the economic status in the Tibetan villages seems to be higher resulting in relatively less

children per family and a better nutritional status. Also education is considered in the Tibetan

villages as equally important for male and female. However there is also an obvious lack of

available health facilities and in general people are reluctant to go to a health post as in their

opinion they do not provide an adequate service.

Conclusion

In the mountain areas of Dolpa the neonatal and under 5 mortality rate is higher than the

Nepal average. Most deliveries still take place without skilled birth attendant under non-

hygienic conditions. The needs include improvement of antenatal care including blood

checks, improved delivery care with stress on hygiene, regular postnatal care. Health

promotion needs to address the importance of avoidance of hypothermia, of immediate

breastfeeding and its exclusive continuation for 6 months.

There are existing health posts, but they are poorly staffed and poorly equipped. Water supply

and water heating systems might be possible without major financial investments. Changing

tradition and habits is a difficult task, but it should not prevent health staff to continue the

efforts for improvements.

Acknowledgments

Special thanks we would like to express to Prof. Trevor Duke, head of the Department for

International Child Health, University of Melbourne, Australia.

We also want to thank the health workers in Dolpa who have been of tremendous help to

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conduct the study and last not least the people of Dolpa who have been supportive and

hospitable wherever and whenever possible.

The authors are grateful to the Ross Trust Fund (Victoria) for funding support.

Declaration of conflicting interest

The authors declared no potential conflicting interest with respect to research, authorship

and/or publication of this article.

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7. Paudel M, Javanparast S, Dasvarma G, Newman L. Religio-cultural factors contributing to perinatal mortality and morbidity in mountain villages of Nepal: Implications for future healthcare provision. Dangal G, editor. PLoS One [Internet]. Public Library of Science; 2018 Mar 15 [cited 2018 Sep 9];13(3):e0194328. Available from: http://dx.plos.org/10.1371/journal.pone.0194328

8. WHO MCEE. MCEE-WHO [Internet]. 2018 [cited 2018 Aug 3]. Available from: http://www.who.int/healthinfo/global_burden_disease/en/

9. Manang.com. Major ethnic groups in Nepal, Sherpa, Gurung, Thakali, Tamang, Rai, Limbu, Tharu, Newar, Dolpo - pa, Brahman / Chhetri, Chepang, MagarManagi [Internet]. 2015 [cited 2018 Dec 4]. Available from: http://www.manang.com/nepal/general_information_about_nepal/people_nepal/major_ethnic_group.php

10. Statistics CB of. National Population and Housing Census 2011 [Internet]. 2014 [cited 2018 Dec 1]. Available from: http://cbs.gov.np/image/data/Population/VDC-Municipality in detail/62 Dolpa_VDCLevelReport.pdf

11. UNICEF. Diarrhoeal disease - UNICEF DATA [Internet]. 2018 [cited 2018 Dec 4]. Available from: https://data.unicef.org/topic/child-health/diarrhoeal-disease/

12. WHO. WHO | From research to national expansion: 20 years’ experience of community-based management of childhood pneumonia in Nepal. Bull WHO. World Health Organization; 2008;86(5).

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13. Banstola A, Banstola A. The epidemiology of hospitalization for pneumonia in children under five in the rural western region of Nepal: a descriptive study. PLoS One [Internet]. Public Library of Science; 2013 [cited 2018 Dec 2];8(8):e71311. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23940739

14. Sathian B, De A, Simkhada P, Malla K, Ghosh A, Basnet S, et al. Time Trend of Pneumonia in under Five Children of Nepal. Am J Public Heal Res Vol 3, 2015, Pages 27-30 [Internet]. Science and Education Publishing; 2015 Jul 1 [cited 2018 Dec 2];3(4A):27–30. Available from: http://pubs.sciepub.com/ajphr/3/4A/5/index.html

15. Mushroom-Appreciation. Cordyceps Sinensis - Facts and Benefits [Internet]. 2018 [cited 2018 Dec 4]. Available from: https://www.mushroom-appreciation.com/cordyceps-sinensis.html

16. Suwal J V. The main determinants of infant mortality in Nepal. Soc Sci Med. 2001;53(12):1667–81.

17. Tamang IK. Underlying Factors for Neonatal Mortality in Nepal [Internet]. 2014 [cited 2018 Sep 9]. Available from: http://bibalex.org/baifa/Attachment/Documents/Z6e27ZVQA3_20161025123708488.pdf

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Table 1: Type of sickness

Type of sickness Frequency

acute watery diarrhoea- 3

ARI- 10

malnutrition- 3

malnutrition+ARI- 1

malnutrition+diarrhoea- 4

TOTAL 21

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Village Population Ethnic under 5 deliveries neon.deaths under 5 mort. Neon. M.rate under 5 m. rate

Tripurakot 2697 Chetri 420 75 8 12 10,67% 16,0%Sahartara 1976 Magar 245 40 1 1 2,50% 2,50%Dunai 2592 Mixed 310 75 5 8 6,67% 10,67%Dho Tarap 520 Tibetan 52 12 1 2 8,33% 16,67%Shipcho 100 Tibetan 6 3 0 0 0,00% 0,00%Tokyu 500 Tibetan 51 11 1 1 9,09% 9,09%Rigmo 300 Tibetan 25 10 1 1 10,00% 10,00%Pugmo 250 Tibetan 20 6 0 0 0,00% 0,00%Ranji 150 Gurung 18 4 0 0 0,00% 0,00%Raha 923 Chetri 150 24 3 5 12,50% 20,83%Dangi Tara 2279 Chetri 300 40 0 0 0,00% 0,00%

TOTAL 12287 1597 300 20 30 6,67% 10,00%

Table 2: Mortality rates

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Footnotes

Contributors: GK collected the data, BK and GK did the study design, the analysis of the data and the interpretation of the data.

Funding: The study received funding from the Ross Trust Fund, Melbourne, Australia, through the University of Melbourne

Competing interests: None declared

Patient consent: Obtained

Ethics approval: Ethics approval was granted by the ‘Nepal Health Research Council’ (NHRC), Ref. No. 743, on Oct. 4th, 2018.

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Confidential: For Review OnlyChild health in a remote rural area in Nepal

A cross-sectional audit and qualitative interviews with parents


Manuscript ID bmjpo-2019-000519.R1

Article Type: Original research

Date Submitted by the Author: 13-Jun-2019

Complete List of Authors: Karki, Bindu ; Charite Medical Faculty BerlinKittel, Guenter ; University of Vienna






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Child health in a remote rural area in Nepal

A cross-sectional audit and qualitative interviews with parents

Guenter Kittel¹, Bindu Karki²

Authors Affiliations:1; University of Vienna2; Charité University, Berlin


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Abstract

Objective: To assess neonatal and under 5 mortality and the health situation for children in

Dolpa, a remote rural area of Nepal.

Study design: Combined quantitative (retrospective cross-sectional) and qualitative (semi-

structured interview).

Rationale:

Progress in reducing under 5 child and newborn mortality has reached the remote areas of

Nepal only to a very limited extent; there appears to be substantial under-reporting and data

may be unreliable. We conducted a quantitative (retrospective cross-sectional) study

evaluating neonatal deaths and childhood morbidity, and a qualitative study (semi-structured

interview) in 10 remote villages in Dolpa district in the north-west of Nepal about the cultural

perception of neonatal death and morbidity.

Setting and participants:

The population of Dolpa district is approximately 35,000. We visited 10 randomly selected

villages (plus one settlement) with approximately 12,000 inhabitants.

Methodology

Records of the number of deliveries, neonatal and under 5 deaths were collected from health

clinics. In addition 100 children (10 different villages) were investigated for the presence of a

disease respective questioned, to determine if any disease has been present during the months

previous to the investigation. Twenty interviews in total were conducted about the cultural

perception of neonatal death and morbidity; in each village at least one interview was taken.

Results

The population of the 10 villages (plus 1 settlement) under investigation was 12,287. 300

deliveries have taken place during the last 12 months before the study. There were 30 cases of

under 5 mortality reported, out of those 20 were neonatal deaths. It reflects a neonatal

mortality rate in Dolpa district of 67 per 1000 live births and an under 5 mortality rate of 100

per 1000. In the previous month, out of 100 children surveyed there had been 11 cases of

ARI, 7 cases of diarrhoea, 3 cases of isolated malnutrition, 5 cases of malnutrition combined

with ARI or diarrhoea.

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Conclusion

There has been progress regarding childhood morbidity and under 5 mortality. However

neonatal mortality is under-reported and has hardly improved during the last years. There is

lack of health staff, but also cultural reasons and perceptions are playing a major role.

Key-words



Key-messages




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to live a traditional life. Religion is of uttermost importance. About 80 per cent of the

population are Hindus and adhere to caste system; about 10 per cent are Buddhists, mainly

living in mountainous regions like Dolpa.

Many parts of the country had been almost impossible to access until 60 years ago and


values, and for the majority of the population, a struggle for daily survival is the reality of life.


a conservative society (2). Those statements are valid for Nepal as whole but particularly for

the Buddhist dominated region of Dolpa. Nepal opened its borders as late as the 1950s, and

many areas still have a restricted access.





above 5000 meters. The district borders Tibet on the North, Jumla and Mugu districts on the

West, Myagdi, Jajarkot and Rukum on the South and Mustang on the East. Dolpa is

influenced culturally by Tibetan Buddhism. The Tibetans mainly live north of the district

capital, Dunai, in scattered smaller villages. Around Dunai there are some relatively large

Hindu Chetri and Brahmin villages, representing about 40-45% of the population. There are

also a few Magar and Gurung villages. The people of Dolpa still live a traditional life-style,

based on subsistence economy and trade.

The problem

Nepal has made a significant improvement reducing the child mortality rate (3). In less than

25 years child-mortality has decreased from 162 deaths per 1000 live births in 1991 to 54 in

2011 according to national data. Nepal has successfully improved coverage of effective




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ways.

According to the 'Nepal Demographic and Health Survey 2016' (6) the overall figures




The main reason for childhood morbidity and mortality are prematurity, intra-partum related

complications, respiratory tract infections, diarrhoeal diseases and injuries (8).

Rationale

We designed this study to understand the health status of children in Dolpa district. We

aimed to have quantitative estimations about children's health outcomes, and qualitative

information on possible cultural reasons for current neonatal care to understand the challenges

to fulfilling Nepal’s ‘Every Newborn Action Plan’ (4).

Figure 1: Map of Nepal

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Methodology

Ten villages (clusters) were randomly selected. The selection included villages with different

ethnic groups (9), two bigger villages mainly inhabited by Chetri, one mainly inhabited by

Magar, the district headquarter Dunai with a mixed population and six other villages, five

inhabited by Tibetans and one by Gurung (10).


Dolpa population of 35,000 people (10), and the villages are representative of the



The main contact persons for investigation were local health staff, the village health

committee and the village leaders. In the only hospital of the region, in Dunai, the nursing

supervisor and the nurses in charge were carefully looking through and interpreting the

records. In Tripurakot and Dangi Tara the nurse in charge provided the information. In

Sahartara we asked five local families about any events during the last year. In Dho Tarap

(including Shipcho), Tokyu and Rigmo due to the absence of health staff the village elders

collected the village committee including the local female health volunteers to give us the

exact numbers for mortality and morbidity. In Pugmo and Ranji the health assistant gave us

the records for those villages. In Raha the health assistant helped us to collect the data from

the village health committee. The same health assistant accompanied us for the full journey,

with his help we cross-checked all data collected from the nurses in charge by asking elders in

the villages about the correctness of the information. As the villages are small, the informant

villagers are well aware about all events, and as the information was cross-checked we

consider the data to be as accurate as is possible from this region.

1. Childhood morbidity.

After discussions with the village leader and the village elders households were randomly

visited and after having received the consent of at least one of the parents, children under

the age of 5 were enrolled in the study.

100 children were investigated (10 in each village) for malnutrition, and if they had acute

lower respiratory infection (ALRI), acute watery diarrhoea or any other disease in the

previous month, including currently. The selection was done by single stage random

sampling. Written consent was sought from the parents, and if given the children were

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included. The sample size was based on an expected prevalence of the presence of a

disease of 20% and at a confidence level of 90%.

2. Neonatal and under 5 mortality.

The total population of the villages under investigation was about 12500 with a total of

about 300 deliveries per year (from November 2017 until the time of the data collection,

which started end of October 2018). We asked health staff and officials, members of the

village health committee and the women’s committee about the number of deliveries, the

number of neonatal deaths and the number of children who have died during the last year.

3. Cultural perceptions of newborn and child health.

Consenting parents were involved in a semi-structured interview about neonatal deaths,

their views on child health, the problems they faced and the actions they are and have

been taking. We used a semi-structured interview to understand: how the death of a new-

born is perceived by the family; whether common childhood diseases are treated or

prevented using local remedies; what solutions the community may propose to improve

the child and new-born health status. One to three interviews were taken in each of 10

villages, a total of 20 interviews. Qualitative interviews were conducted in Nepali or

Tibetan by the accompanying health assistant and then immediately transcribed in

English. All interviews were done in a private environment respecting the dignity of the

participants and with their full consent.

See also ‘Semi-structured interview’ (supplementary file)

As part of the study the results were disseminated to the district authorities with the aim to

improve interventions.


Quantitative data on neonatal deaths and child morbidity were analysed with EpiInfo 7

software and Excel.

Ethics



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Results

Childhood Morbidity


during the previous month. There was general agreement by parents and health workers that

pneumonia is the main problem for childhood morbidity.





Due to lack of other facilities we used MUAC (mid upper arm circumference) as a diagnostic

tool for protein-energy malnutrition. Eight children had malnutrition; in 4 cases there was a

combination of malnutrition with diarrhoea, in 1 case a combination of pneumonia and

malnutrition at the time of investigation. All cases of malnutrition were seen in the Chetri

villages; in the Tibetan villages no malnutrition was diagnosed.



Injuries including burns obviously did not play a major role for the childhood morbidity in

Dolpa district, among the relatively small sample.








neonatal deaths could not be given.

10 children older than 28 days had died during last year, 5 were suffering from pneumonia,

and 5 were suffering from bloody diarrhoea. The under-5-mortality rate for the area of study

was estimated to be 100 per 1000 live births.

Interviews

20 village members, 1-3 in each of the 10 villages, were asked about their perception of

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neonatal death and about any sickness of their children as well as their approach for a

solution.

How the death of a newborn is perceived by the family: families generally agreed that the

death of a newborn is a natural event which has to be accepted. The reason behind are karma




Ditya tells:





Sabitri teels:



was born I had to stay for 9 days at home. It was winter and was very cold. The baby





Dolma tells:






remedies: most families try to get modern medicine like antibiotics in case of any disease of

their children.

Hara tells:



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Yangchen tells:







Goma tells:





anymore.’

Which solutions the community is proposing as prevention: the 3 women interviewed in the




there.




The following reply in Dho Tarap, a Tibetan village:








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like Kathmandu or Pokhara.

We saw health posts without staff present, or if the staff was present there was no medicine.

Some were posts were lacking water, and even the district hospital had no warm water supply.

On the other hand we found a couple of dedicated nurses, so the judgements of some

interviewed mothers might be also based on some misconceptions, like medicine from tourists

is ‘good medicine’, even without having any idea about indication or dosage. To go for

medical treatment to Kathmandu seemed to be also a question of the social status and the




Quite often people went for medicine to a health post but at the same time they also tried local

remedies to find a cure, mainly by performing ceremonies.

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Discussion

Childhood Morbidity

Although our sample was relatively small, childhood morbidity in Dolpa seemed relatively

low in comparison to the Nepal average (11–14). Respiratory infections were common in the

colder regions inhabited by mainly Tibetans whereas diarrhoea has been more common in the

lower regions mainly inhabited by Chetris.


Tripurakot and Raha, whereas in the other villages malnutrition was not identified as a

problem. Although the economic situation was not part of the study it appears to be highly

likely that the level of income plays an important role. The Tibetan villages are economically


Yartsa Gunbu or Cordyceps Sinensis (15), by trade with China and the fast growing tourism

industry.



We were told that this problem exists for most time of the year. Despite this, vaccinations

campaigns are taking place and as people are aware of the advantage of vaccinations there

seems to be a high coverage rate.



indication. (Table 1)

Table 1

Type of sickness








skilled.

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According to our findings the number of neonatal deaths was 67/1000; twice the estimated

average figures for the whole of Nepal (17). A previous report of infant mortality in a

neighbouring district of Mugu was even higher at 201/1000 (16).





available. (Table 2)

Table 2

Mortality rates


The qualitative part of this study identified several traditions that affect child and newborn

health.




connected with supernatural beliefs. For the first days after delivery the neonates should not





Despite these strong traditions, people were open and were hoping for improvements. They

have been grateful for health services provided and expressed their wish for a permanent

service. Although fatalism has been often addressed as a key factor for non-reporting of

neonatal deaths and non-acceptance of changes, an approach including more active

community participation through strengthening of health promotion could lead to positive

results (7). There is surely readiness and hope from the side of the community.

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Limitations

Major difficulties for the collection of data were the lack of health facilities, and if health

facilities were present there was lack of health staff, and overall there was lack of records.

The interviewed health workers generally agreed that most children are not taken to a health


usually not reported. Another problem was the definition of ARI. Regarding ARI we had to

confine to the definition of cough and fever, the assessment for fast breathing has been vague.

So we were mostly dependent on information from parents or village elders.





and the economic status in the Tibetan villages seems to be higher resulting in relatively fewer





Summary and Conclusion

In the mountain areas of Nepal the neonatal mortality rate is continuing to be and is higher

than the Nepal average (16).

The main reasons are lack of infrastructure, lack of trained staff, lack of birth facilities, lack of

education and lack of health promotion. Most deliveries still take place without skilled birth

attendant under non-hygienic conditions (5).

Religio-cultural factors are playing a major role for the lack of improvements. Acceptance of

neonatal death as it interpreted as Karma, as fate due to previous bad deeds, is one of the

major reasons that treatable conditions are neglected (7).

By this study we did not only rely on retrospective data from different health posts, but we

collected the information mostly directly from the people concerned. We could show that it

is possible to do with relatively little financial means. It has helped to fill the gap of un-

reported data, especially regarding neonatal mortality.

The interviews have shown that many local perceptions affect health care seeking, referral

patterns and outcomes. Due to lack of trust into the local health facilities, antibiotics and other

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medicine are used indifferently and much funds are spent on often unnecessary referrals into

the main centres.

There is need for proper staffing in the existing health posts with the goal to be successful by

simple interventions, which have been successful in Nepal during the last years, especially the

Aama programme, the ‘female community health volunteer programme, the community-based

IMCI and the community-based newborn care (18).

Water supply and water heating systems might be possible without major financial

investments. By adequate health promotion an introduction or a reinforcement of those

programmes, including especially regular antenatal care, improved delivery care with stress

on hygiene, addressing the importance of avoidance of hypothermia, of immediate

breastfeeding and regular postnatal care should have a good chance to reduce the neonatal

mortality rate substantially. Changing tradition and habits is a difficult task, but it should not

prevent health staff to continue the efforts for improvements.

Acknowledgments

Special thanks we would like to express to Prof. Trevor Duke, head of the Department for

International Child Health, University of Melbourne, Australia.








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Bibliography



3. Pradhan Y V, Upreti SR, Pratap KC N, KC A, Khadka N, Syed U, et al. Newborn survival in Nepal: a decade of change and future implications. Health Policy Plan [Internet]. 2012 Jul 1 [cited 2018 Sep 9];27(suppl_3):iii57–71. Available from: https://academic.oup.com/heapol/article/27/suppl_3/iii57/584074


5. Reesha J. Improving neonatal health in nepal: major challenges to achieving millennium development goal 4. Heal Sci J [Internet]. 2013 [cited 2018 Sep 9];7(3). Available from: http://www.hsj.gr/medicine/improving-neonatal-health-in-nepal-major-challenges-to-achieving-millennium-development-goal-4.php?aid=2946


7. Paudel M, Javanparast S, Dasvarma G, Newman L. Religio-cultural factors contributing to perinatal mortality and morbidity in mountain villages of Nepal: Implications for future healthcare provision. Dangal G, editor. PLoS One [Internet]. 2018 Mar 15 [cited 2018 Sep 9];13(3):e0194328. Available from: http://dx.plos.org/10.1371/journal.pone.0194328





12. WHO. WHO | From research to national expansion: 20 years’ experience of community-based management of childhood pneumonia in Nepal. Bull WHO. 2008;86(5).

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13. Banstola A, Banstola A. The epidemiology of hospitalization for pneumonia in children under five in the rural western region of Nepal: a descriptive study. PLoS One [Internet]. 2013 [cited 2018 Dec 2];8(8):e71311. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23940739

14. Sathian B, De A, Simkhada P, Malla K, Ghosh A, Basnet S, et al. Time Trend of Pneumonia in under Five Children of Nepal. Am J Public Heal Res Vol 3, 2015, Pages 27-30 [Internet]. 2015 Jul 1 [cited 2018 Dec 2];3(4A):27–30. Available from: http://pubs.sciepub.com/ajphr/3/4A/5/index.html




18. Paudel Punya BH. Aama and New Born Programme: A Programme for Saving Lives of Women and New Born in Nepal [Internet]. 2017 [cited 2019 May 15]. Available from: http://www.nhssp.org.np/NHSSP_Archives/health_financing/Aama_and_newborn_programme_brief_policy_january2017.pdf

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ARI- 10

malnutrition- 3

malnutrition+ARI- 1


TOTAL 21

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Village Population Ethnic under 5 Deliveries neon.deaths under 5 mort. Neon. M.rate (per 1000 live births)

under 5 m. rate(per 1000 live births)

Tripurakot 2697 Chetri 420 75 8 12 107/1000 160/1000Sahartara 1976 Magar 245 40 1 1 25/1000 25/1000Dunai 2592 Mixed 310 75 5 8 70/1000 107/1000Dho Tarap 520 Tibetan 52 12 1 2 83/1000 170/1000Shipcho 100 Tibetan 6 3 0 0 0,00 0,00Tokyu 500 Tibetan 51 11 1 1 91/1000 91/1000Rigmo 300 Tibetan 25 10 1 1 100/1000 100/1000Pugmo 250 Tibetan 20 6 0 0 0,00 0,00Ranji 150 Gurung 18 4 0 0 0,00 0,00Raha 923 Chetri 150 24 3 5 125/1000 208/1000Dangi Tara 2279 Chetri 300 40 0 0 0,00 0,00

TOTAL 12287 1597 300 20 30 67/1000 100/1000


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Footnotes






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Confidential: For Review OnlySemi-structured interview questions(Research Dolpa, Nepal, 2018)

The research questions will be done in a comfortable and familiar environment in the local language, either in Nepali or Tibetan.

1., How the death of a new-born is perceived by the family:Which reasons are considered to be behind it.Is it the will of gods?Is it fate?Is it due to wrong behaviour?Is it considered serious?Is there anyone blamed for it?Which consequences does it have for the woman and for the family?

2., How the main childhood diseases like ARI’s and diarrhoeal diseases are prevented by local remedies: Which is the preferred treatment for childhood illnesses.Are traditional remedies the first choice?And if, which remedies are used?Are traditional faith healers commonly called?Are modern treatments preferred, if available?Are local remedies and modern treatments used in combination?

3., Which solutions the community is proposing as prevention:Is there enough health staff provided?Are there enough health posts?Is the health staff in your opinion competent?Is the health staff usually providing sufficient support?Should be more local staff be involved?Do you have trust in the government health staff?Or would you prefer a re-vitalisation of the traditional medicine?Is there sufficient medicine available?How does a referral work?

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Confidential: For Review OnlyNeonatal mortality and child health in a remote rural area in

Nepal A cross-sectional audit and qualitative interviews with

parents




Date Submitted by the Author: 12-Aug-2019







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Neonatal mortality and child health in a remote rural area in NepalA cross-sectional audit and qualitative interviews with parents

Bindu Karki¹, Guenter Kittel²

Authors Affiliations:1; Charité University, Berlin

2; University of Vienna


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Abstract

Objective: To assess neonatal and under 5 mortality and the health situation for children in


Study design: Mixed methods: quantitative (retrospective cross-sectional) and qualitative

(semi-structured interviews).

Rationale: Progress in reducing child and newborn mortality in Nepal has reached the remote

areas to a limited extent. Furthermore there may be substantial under-reporting and data may

be unreliable.

Setting and participants: The population of Dolpa district is approximately 35,000. We

visited 10 randomly selected villages (plus one settlement) with approximately 12,000

inhabitants.

Methodology: Records of the number of deliveries, neonatal and under 5 deaths were

collected. 100 children (10 different villages) were evaluated for common diseases present

during the month prior to the investigation. Twenty interviews were conducted about the

cultural perceptions of neonatal death and morbidity; in each village at least one interview

was taken.

Results: The population of the 10 villages (plus 1 settlement) under investigation was 12,287.

Three hundred deliveries have taken place during the last 12 months before the study. There

were 30 children reported to have died; out of those 20 were in the neonatal period. This

reflects a neonatal mortality rate in Dolpa district of 67/1000 live births (95% CI 41-

101/1000) and an under 5 mortality rate of 100/1000 (95% CI 70-140/1000). In the previous

month, out of 100 children surveyed there had been 11 cases of ARI, 7 cases of diarrhoea, 3

cases of isolated malnutrition, and 5 cases of malnutrition combined with ARI or diarrhoea.

Based on qualitative interviews traditional beliefs still play a major role, and are partly a

hindrance to progress in health. There is also mistrust in the health services and

misconceptions about ‘modern’ medicine and treatment facilities.

Conclusion: Despite progress in child morbidity and mortality in Nepal, some areas remain

underserved by health services and neonatal mortality is far above the Nepalese average,

which is 29/1000 live births. There is a substantial need to increase and train health staff.

Health promotion should be encouraged but cultural perceptions have to be understood if

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3

positive behavioural change is to be achieved.

Key-words



Key-messages




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to live a traditional life. Religion is of utmost importance. About 80 per cent of the population

are Hindus and adhere to the caste system; about 10 per cent are Buddhists, mainly living in

mountainous regions like Dolpa.

Many parts of the country had been almost impossible to access until 60 years ago, and


values, and for the majority of the population a struggle for survival is the reality of life.


a conservative society (2). Those statements are valid for Nepal as whole, and particularly for

the Buddhist dominated region of Dolpa.





above 5000 meters. Dolpa is influenced culturally by Tibetan Buddhism. The Tibetans mainly

live north of the district capital, Dunai, in scattered smaller villages. Around Dunai there are

some relatively large Hindu Chetri and Brahmin villages, representing about 40-45% of the

population. There are also a few Magar and Gurung villages. The people of Dolpa still live a

traditional life-style, based on subsistence economy and trade.

The problem

Nepal has made a significant improvement reducing the child mortality rate (3). Within 25

years the under 5-mortality decreased from 133 deaths per 100 live births in 1991 to 39 deaths

per 1000 live births in 2016 (4,5) according to national data. Even neonatal mortality, which

has made the slowest progress globally, has decreased from 50 deaths per 1000 live births in

1991 to 29 in 2016 (4–6). Nepal has successfully improved coverage of effective






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ways.

According to the 'Nepal Demographic and Health Survey 2016' (4,6) the overall figures




The main reason for neonatal mortality are prematurity, neonatal sepsis and intra-partum

related complications, for childhood morbidity respiratory tract infections, diarrhoeal diseases

and injuries (10).

Rationale

We designed this study to understand the health status of children in Dolpa district. We aimed

to have quantitative estimations about neonatal and under 5 mortality children's health

outcomes in general, and qualitative information on possible cultural reasons for current

neonatal care to understand the challenges to fulfilling Nepal’s ‘Every Newborn Action Plan’

(7). The aim of the study has been to analyse the obstacles, and to contribute in finding a way

to improve the present situation in areas with very limited access.

Figure 1: Map of Nepal

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Methodology

Ten villages (clusters) were randomly selected. These included villages with different ethnic

groups (11), two bigger villages mainly inhabited by Chetri, one mainly inhabited by Magar,

the district headquarter Dunai with a mixed population and six other villages, five inhabited

by Tibetans and one by Gurung (12).





For the investigation on childhood morbidity the sample size of 100 children (10 clusters

with 10 children each cluster) was based on an expected prevalence of the presence of a

disease of 20% and at a confidence level of 90%. 10 clusters (villages) were randomly

selected. 10 children in each cluster (100 children in total) were examined. After

discussions with the village leader and the village elders the randomly selected households

were visited and after having received the consent of at least one of the parents, children

under the age of 5 were enrolled in the study.


lower respiratory infection (ALRI), acute watery diarrhoea, which are the prevalent

childhood diseases (4) or any other disease in the previous month, including currently.

The selection was done by single stage random sampling. Written consent was sought

from the parents, and if given the children were included.

Due to lack of other facilities we used MUAC (mid upper arm circumference) as a

diagnostic tool for protein-energy malnutrition. Regarding ARI we confined the definition

of cough and fever, the assessment for fast breathing has been vague. For acute watery

diarrhoea we used the usual definition of more than 3 loose stools per day for less than 14

days.

2. Neonatal and under 5 mortality.

For neonatal mortality we estimated the total number of deliveries in the Dolpa district

within one year at around 1000. We expected a neonatal mortality of around 50/1000 at a

confidence level of 95%.


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which started end of October 2018).

3. Cultural perceptions of new-born and child health (qualitative part).

The interviews were conducted by one author (GK). He is a surgeon with a long

background in public health issues, and also with a background in social anthropology.

The questions and answers were simultaneously translated into the local dialect by the

accompanying health professional. The principles of discourse analysis were followed.

The participants were chosen as much as possible randomly, but partly also to

convenience, as some have been more eager to speak out than others. The themes were

identified in advance (13).

Consenting parents were involved in a semi-structured interview about neonatal deaths,

their views on child health, the problems they faced and the actions they are and have

been taking. We used a semi-structured interview to understand: how the death of a new-

born is perceived by the family; whether common childhood diseases are treated or

prevented using local remedies; what solutions the community may propose to improve

the child and new-born health status. One to three interviews were taken in each of 10

villages, a total of 20 interviews. Qualitative interviews were conducted in Nepali or

Tibetan by the accompanying health assistant and then immediately transcribed into

English. All interviews were done in a private environment respecting the dignity of the

participants and with their full consent.














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consider the data to be as accurate as it is possible from this region.




Quantitative data on neonatal deaths and child morbidity were analysed with Epi Info 7

software and Excel.

Ethics



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9

Results

Childhood Morbidity

For the data on morbidity we mainly relied on the information provided by parents. In the 10

villages (clusters) randomly selected there was a rather equal geographical distribution.

Parents of eleven out of hundred children surveyed reported an acute lower respiratory

infection during the previous month.





8 children had malnutrition; in 4 cases there was a combination of malnutrition with

diarrhoea, in 1 case a combination of pneumonia and malnutrition at the time of investigation.

All cases of malnutrition were seen in the Chetri villages; in the Tibetan villages no

malnutrition was diagnosed.





There was general agreement by parents and health workers that pneumonia followed by

acute watery diarrhoea are the main problems for childhood morbidity.








neonatal deaths could not be given.

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10

10 children older than 28 days had died during last year, 5 were suffering from pneumonia,

and 5 were suffering from bloody diarrhoea. The under-5-mortality rate for the area of study

was estimated to be 100 per 1000 live births (95% CI 70-140/1000).

Interviews

General discussions were held with the members of the women’s committee of the villages.

Randomly we selected 1-3 women in each of the 10 villages, altogether 20 women. They were

asked about their perception of neonatal death and about any sickness of their children as well

as their approach for a solution.

How the death of a newborn is perceived by the family: Families generally agreed that the





The names of the mothers do not reflect their real names.

Ditya tells:





Sabitri teels:



was born I had to stay for 9 days at home. It was winter and it was very cold. The baby





Dolma tells:





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remedies: Most families try to get modern medicine like antibiotics in case of any disease of

their children.

Hara tells:





Yangchen tells:

‘My daughter had diarrhoea for a couple of days. I also noticed that there was blood in

her stool. She was very sick and lost a lot of weight. I was very worried that she would

die. So I went to the next health post. The nurse gave me medicine, but it still did not

improve. Then I looked for our Amchi (doctor practising traditional medicine). He

took very well care of my daughter and finally after weeks she recovered. Now she is a

strong young girl.’

Goma tells:





anymore.’

Which solutions the community is proposing as prevention: The 3 women interviewed in the




there.







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Discussion

Childhood Morbidity

Although our sample was relatively small, childhood morbidity in Dolpa did not exceed the

average data for Nepal (4,6,14–17). Respiratory infections (11 out of 100) were common in

the colder regions inhabited by mainly Tibetans whereas diarrhoea (7 out of 100) has been

more common in the lower regions mainly inhabited by Chetris. Malnourished children were

only found in two Chetri villages, whereas in the other villages malnutrition was not identified

as a problem. Although the economic situation was not part of the study it appears to be

highly likely that the level of income plays an important role. The Tibetan villages are

economically better off than the Chetri communities. Reasons are the generating of income by

the sale of Yartsa Gunbu or Cordyceps Sinensis (18), by trade with China and the fast

growing tourism industry. The acceptance of family planning and the economic status in the

Tibetan villages seems to be higher resulting in relatively fewer children per family and a

better nutritional status. Also education is considered in the Tibetan villages as equally

important for male and female.



We were told that this problem exists for most time of the year. Despite this, vaccinations

campaigns are taking place and as people are aware of the advantage of vaccinations there

seems to be a high coverage rate.



indication.


like Kathmandu or Pokhara. The judgements of some interviewed mothers might be also

based on some misconceptions, like medicine from tourists is ‘good medicine’, even without

having any idea about indication or dosage. To go for medical treatment to Kathmandu

seemed to be also a question of the social status and the dedication of local nurses and the

importance of medical knowledge and proper clinical examination have been generally

underestimated and the possibilities in the capital with CT and other expensive procedures

highly overestimated.

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However there is also an obvious lack of available health facilities and in general people are

reluctant to go to a health post as in their opinion they do not provide an adequate service.

Table 1

Type of sickness








skilled.




According to our findings the number of neonatal deaths was 67/1000 (CI: 41-101/1000);

twice the estimated average figures for the whole of Nepal (4,20). A previous report of infant

mortality in a neighbouring district of Mugu was even higher at 201/1000 (19).





available.

Table 2

Mortality rates



health.



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Despite strong traditions, people were open and were hoping for improvements. They have

been grateful for health services provided and expressed their wish for a permanent service.

Although fatalism has been often addressed as a key factor for non-reporting of neonatal

deaths and non-acceptance of changes, an approach including more active community

participation through strengthening of health promotion could lead to positive results (9).

There is surely readiness and hope from the side of the community.

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Limitations





usually not reported. So we were mostly dependent on information from parents or village

elders.


average age for the first delivery, the spacing, the educational level and the differences in the

economic status, but it was obvious that there is a difference between the mainly by Chetri

populated villages in the south of Dolpa and the Tibetan villages in the north.


In the mountain areas of Nepal the neonatal mortality rate is higher than the Nepal average

(19).


education and lack of health promotion. Most deliveries still take place without skilled birth


Religio-cultural factors play a major role for the lack of improvements. Acceptance of

neonatal death as it is interpreted as Karma, as fate due to previous bad deeds, is one of the



collected the information mostly directly from the people concerned. We could show that it is

possible to do with relatively little financial means. It has helped to fill the gap of un-reported

data, especially regarding neonatal mortality.



medicine are used indifferently and much funds are spent on often unnecessary referrals to the

main centres.



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Aama programme, the ‘female community health volunteer programme, the community-based


Acknowledgments

Special thanks we would like to express to Prof. Trevor Duke, Centre for International Child

Health, University of Melbourne, Australia.








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Bibliography




4. Ministry of Health and Population (MOHP). Nepal Demographic and Health Survey. Kathmandu; 2017.

5. World Bank. Mortality rate, under 5 [Internet]. The World Bank. 2019. Available from: https://data.worldbank.org/indicator/SH.DYN.MORT?locations=NP&most_recent_year_desc=false



8. Reesha J. Improving neonatal health in nepal: major challenges to achieving millennium development goal 4. Heal Sci J [Internet]. 2013 [cited 2018 Sep 9];7(3). Available from: http://www.hsj.gr/medicine/improving-neonatal-health-in-nepal-major-challenges-to-achieving-millennium-development-goal-4.php?aid=2946





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13. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): A 32-item checklist for interviews and focus groups. Int J Qual Heal Care. 2007;









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ARI- 10

malnutrition- 3

malnutrition+ARI- 1


TOTAL 21

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Village Population Ethnic under 5 Deliveries neon.deaths under 5 mort. Neon. M.rate (per 1000 live births)

under 5 m. rate(per 1000 live births)

Tripurakot 2697 Chetri 420 75 8 12 107/1000 160/1000Sahartara 1976 Magar 245 40 1 1 25/1000 25/1000Dunai 2592 Mixed 310 75 5 8 70/1000 107/1000Dho Tarap 520 Tibetan 52 12 1 2 83/1000 170/1000Shipcho 100 Tibetan 6 3 0 0 0,00 0,00Tokyu 500 Tibetan 51 11 1 1 91/1000 91/1000Rigmo 300 Tibetan 25 10 1 1 100/1000 100/1000Pugmo 250 Tibetan 20 6 0 0 0,00 0,00Ranji 150 Gurung 18 4 0 0 0,00 0,00Raha 923 Chetri 150 24 3 5 125/1000 208/1000Dangi Tara 2279 Chetri 300 40 0 0 0,00 0,00

TOTAL 12287 1597 300 20 30 67/1000 100/1000


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Footnotes

Contributors: GK collected the data and has done the interviews, BK and GK did the study design, GK has developed the section on methodology, BK and GK did the analysis of the data and the interpretation of the data, BK and GK developed together the discussion as well as the summary and conclusion. Professor Trevor Duke (TK) served as senior academic adviser.





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84x71mm (300 x 300 DPI)

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Confidential: For Review OnlySemi-structured interview questions

(Research Dolpa, Nepal, 2018)

The research questions will be done in a comfortable and familiar environment in the local language,

either in Nepali or Tibetan.

1., How the death of a new-born is perceived by the family:

Which reasons are considered to be behind it.

Is it the will of gods?

Is it fate?

Is it due to wrong behaviour?

Is it considered serious?

Is there anyone blamed for it?

Which consequences does it have for the woman and for the family?

2., How the main childhood diseases like ARI’s and diarrhoeal diseases are prevented by

local remedies:

Which is the preferred treatment for childhood illnesses.

Are traditional remedies the first choice?

And if, which remedies are used?

Are traditional faith healers commonly called?

Are modern treatments preferred, if available?

Are local remedies and modern treatments used in combination?

3., Which solutions the community is proposing as prevention:

Is there enough health staff provided?

Are there enough health posts?

Is the health staff in your opinion competent?

Is the health staff usually providing sufficient support?

Should be more local staff be involved?

Do you have trust in the government health staff?

Or would you prefer a re-vitalisation of the traditional medicine?

Is there sufficient medicine available?

How does a referral work?

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Nepal A cross-sectional audit and qualitative interviews with

parents











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Neonatal mortality and child health in a remote rural area in NepalA cross-sectional audit and qualitative interviews with parents


Authors Affiliations:1; Charité University, Berlin2; University of Vienna


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2

Abstract

Objective: To assess neonatal and under five mortality and the health situation for children in






be unreliable.


visited ten randomly selected villages (plus one settlement) with approximately 12,000

inhabitants.

Methodology: Records of the number of deliveries, neonatal and under five deaths were


during the month prior to the investigation. Twenty interviews were conducted about the

cultural perceptions of neonatal death and morbidity; in each village at least one interview

was undertaken.

Results: The population of the 10 villages (plus one settlement) under investigation was

12,287. Three hundred deliveries have taken place during the last twelve months before the

study. There were 30 children reported to have died; out of those 20 were in the neonatal

period. This reflects an estimated neonatal mortality rate in Dolpa district of 67/1000 live

births (95% CI 41-101/1000) and an estimated under five mortality rate of 100/1000 (95% CI

70-140/1000). In the previous month, out of 100 children surveyed there had been eleven

cases of ALRI, seven cases of diarrhoea, three cases of isolated malnutrition, and five cases of

malnutrition combined with ALRI or diarrhoea.







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Key-words



Key-messages

There is under-reporting of neonatal mortality in the region

There is a substantial need to increase appropriately trained health staff, who also need to

respond to the cultural context.

There is need for adequate health promotion to improve hygiene and to work on better

acceptance of health services.

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4







Many parts of the country had been almost impossible to access until sixty years ago, and



Innovations may be observed with interest, but changes and adaptations are not the strength of












The problem


years the under five mortality decreased from 133 deaths per 100 live births in 1991 to 39

deaths per 1000 live births in 2016 (4,5) according to national data. Even neonatal mortality,

which has made the slowest progress globally, has decreased from 50 deaths per 1000 live

births in 1991 to 29 in 2016 (4,5). Nepal has successfully improved coverage of effective

interventions to prevent or treat the most important causes of child mortality through a variety


high coverage of six monthly vitamin A supplementation and deworming, the integrated



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However, access to health care and to community-based child health interventions varies. The




ways.







and injuries (10).

Rationale


to have quantitative estimations about neonatal and under five mortality, children's health



(6).

The aim of the study was to analyse the obstacles, and to contribute to finding ways to

improve the present situation in areas with limited access.

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Methodology

Ten villages (clusters) were randomly selected. These included villages with different ethnic


the district headquarter Dunai with a mixed but mainly Chetri population and six other

villages, five inhabited by Tibetans and one by Gurung (12).

The ten villages included in the study had a total population of about 12,000 out of the total










under the age of five were enrolled in the study.







diagnostic tool for protein-energy malnutrition. Regarding ALRI we confined the

definition of cough and fever, the assessment for fast breathing has been vague. For acute

watery diarrhoea we used the usual definition of more than three loose stools per day for

less than fourteen days.

2. Neonatal and under five mortality.





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3. Cultural perceptions of newborn and child health (qualitative part).




accompanying health professional. The principles of discourse analysis were followed

(13). The participants were chosen as much as possible randomly, but partly also to

convenience, as some have been more eager to speak out than others. Consenting parents

were involved in a semi-structured interview about neonatal deaths, their views on child

health, the problems they faced and the actions they are and have been taking. We used a

semi-structured interview to understand: how the death of a new-born is perceived by the

family; whether common childhood diseases are treated or prevented using local

remedies; what solutions the community may propose to improve the child and newborn

health status. One to three interviews were taken in each of 10 villages, a total of 20

interviews. Qualitative interviews were conducted in Nepali or Tibetan by the

accompanying health assistant and then immediately transcribed in English. All interviews

were done in a private environment respecting the dignity of the participants and with

their full consent.















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Quantitative data on neonatal deaths and child morbidity were analysed with Epi Info 7

software and Excel.

Ethics



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Results

Childhood Morbidity

For the data on morbidity we mainly relied on the information provided by parents. In the ten



during the previous month.

Parents of seven children out of 100 reported their child suffering from acute watery diarrhoea

during the previous month. Diarrhoea was more common in the Chetri (five cases) than in the

Tibetan population (two cases). In four cases there was a combination of malnourishment and


Eight children had malnutrition; in four cases there was a combination of malnutrition with

diarrhoea, in one case a combination of pneumonia and malnutrition at the time of

investigation. All cases of malnutrition were seen in the Chetri villages; in the Tibetan

villages no malnutrition was diagnosed.

One child suffering from malnutrition and ALRI had congenital heart disease. No other

disease was diagnosed for the children under investigation.





Estimated neonatal and childhood mortality



reflects an estimated neonatal mortality rate of 67/1000 (95% confidence interval 41-

101/1000).

The highest neonatal mortality appeared to be in Chetri villages in the southern part of Dolpa

with the exception of one village (Dangi Tara), where not a single death was reported. A

possible reason for the exception is a better access to health facilities due its immediate

proximity to the airport. There was general agreement that most deliveries take place at home

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without trained birth attendant and that neonatal deaths are usually not reported. Reasons for

most of the neonatal deaths could not be given.

Ten children older than 28 days had died during last year, five were suffering from

pneumonia, and five were suffering from bloody diarrhoea. The under five mortality rate for

the area of study was estimated to be 100 per 1000 live births (95% CI 70-140/1000).

Interviews


Randomly we selected one to three women in each of the ten villages, altogether twenty

women. They were asked about their perception of neonatal death and about any sickness of

their children as well as their approach for a solution.






The names of the mothers at the end of the interviews do not reflect their real names.





(Ditya, mother of two sons and one daughter)

‘My marriage took place when I was only fourteen years old. Only few years later I

got pregnant for the first time. I do not know how old I have been then. After a baby

girl was born I had to stay for nine days at home. It was winter and was very cold. The

baby got sick shortly after delivery. I was thinking to go to a doctor but I was told that

the cause of the fever is Bhut (bad spirit, evil eye) and whatever happens would be

God’s will. After two weeks the baby died. Fortunately a year later I got pregnant

again and gave birth to a healthy son. My family was very happy.’

Sabitri (mother of two sons and two daughters)



knew I would get pregnant again so I was not too unhappy. Eighteen months later I

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gave birth to a healthy boy. Now I have two boys, they are fine.’

Dolma (mother of two sons)



their children.





Hara (mother of one son and three daughters)







Yangchen (mother of one daughter)

‘When my son was about two years old he had repeated attacks of diarrhoea. He

started to lose weight. After one to two months I thought he might die. We went to our

health post but the health worker was not present. So we performed a ceremony

(Chakri) at our home. A few days later my son recovered and since then he hardly got

sick anymore.’

Goma (mother of one son)

Which solutions the community is proposing as prevention: The three women interviewed in

the district capital Dunai were satisfied with the service of the district hospital. They said that

most of the time nurses are present and are providing a proper service to patients.

Two women living close to Tapriza also appreciated the service provided by the health post

there.

The other fifteen women, living in villages with far distance to a health post or experiencing

the constant absence of staff all expressed the wish for a health post with permanent staffing.

The answers were all similar.

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Discussion

Although our sample was relatively small, childhood morbidity in Dolpa did not exceed the

average data for Nepal (4,8,14–17). Respiratory infections were common in the colder regions

inhabited by mainly Tibetans whereas diarrhoea has been more common in the lower regions

mainly inhabited by Chetris.



problem. Although the economic situation was not part of the study it appears to be highly

likely that the level of income plays an important role. The Tibetan villages are economically


Yartsa Gunbu or Cordyceps Sinensis, by trade with China and the fast growing tourism

industry.

Previous studies in Nepal have shown considerable disparities in neonatal, infant and under

five mortality. Studies in the Mugu District (a neighbouring district to Dolpa) in 2000 have


We estimated the number of neonatal deaths to be 67/1000 (CI: 41-101/1000), twice the

estimated average figures for the whole of Nepal (4,19). A previous report of infant mortality

in a neighbouring district of Mugu was even higher at 201/1000 (18).


deaths are not reported. Deliveries are usually taking place at home and are attended by an


skilled.


been some in previous years. If finances are allowing a few pregnant mothers are going to

Kathmandu for delivery.


health.

In the Chetri villages girls are married at an early age, some of them at the age of fourteen and

in few cases even below that age. The first pregnancy is taking place as a consequence mostly

before having reached the age of twenty. Birth and the neonatal period are always strongly


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based on some misconceptions, like medicine from tourists is ‘good medicine’. To go for

medical treatment to Kathmandu seemed to be also a question of social status and the






indication. The main reasons for observed improvements appear to be successful vaccination

campaigns and economic progress in some regions. On the other hand there is obvious lack of

ante- and postnatal care, home deliveries without the presence of skilled birth attendants are

still taking place in the majority of cases and there is lack of hygienic conditions as warm

water is hardly available.







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Limitations






elders.












(18).


education and lack of health promotion. Most deliveries still take place without a skilled birth



neonatal death as it interpreted as Karma, as fate due to previous bad deeds, is one of the








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medicines are used indifferently and much funds are spent on often unnecessary referrals into

the main centres.



Aama programme, the female community health volunteer programme, the community-based


An adequate health promotion could concentrate on improving hygiene and on better


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Acknowledgments



We also want to thank the health workers in Dolpa, who have been of tremendous help to

conduct the study and last not least the people of Dolpa, who have been supportive and






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Bibliography

1. Legatum Prosperity Index. Nepal. Legatum Prosper Index [Internet]. 2016 [cited 2018 Jan 8]; Available from: www.prosperity.com




5. World Bank. Mortality rate, under 5 [Internet]. The World Bank. 2019. Available from: https://data.worldbank.org/indicator/SH.DYN.MORT?locations=NP&most_recent_year_desc=false


7. Reesha J. Improving neonatal health in Nepal: major challenges to achieving millennium development goal 4. Heal Sci J [Internet]. 2013 [cited 2018 Sep 9];7(3). Available from: http://www.hsj.gr/medicine/improving-neonatal-health-in-nepal-major-challenges-to-achieving-millennium-development-goal-4.php?aid=2946

8. Ministry of Health. Nepal Demographic and Health Survey 2016 Key Indicators Report [Internet]. Kathmandu; 2017 [cited 2018 Sep 7]. Available from: www.DHSprogram.com.





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19

13. Shanthi A, Wah LK, Lajium D. Discourse Analysis as a Qualitative Approach to Study Information Sharing Practice in Malaysian Board Forums. Int J E-Learning Pract. 2015;2(November 2016):159–69.






19. Tamang IK. Underlying Factors for Neonatal Mortality in Nepal [Internet]. Vrije Universiteit Amsterdam; 2014 [cited 2018 Sep 9]. Available from: http://bibalex.org/baifa/Attachment/Documents/Z6e27ZVQA3_20161025123708488.pdf


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Table 1: Neonatal and under 5 deaths

Estimated total neonatal mortality rate: 6,67%

Estimated mortality rate for under 5 population: 10,0

Comparison according to ethnic groups :

Ethnic group Population Under 5 population Deliveries Neon.deaths Under 5 mortality

Chetri 8491 1180 214 16 25Tibetan 1670 154 42 3 4Others 2126 263 44 1 1

Village Population Ethnic Under 5 population Deliveries Neon. deaths Under 5 deaths

Dunai 2592 Chetri (mainly) 310 75 5 8Tripurakot 2697 Chetri 420 75 8 12Raha 923 Chetri 150 24 3 5Dangi Tara 2279 Chetri 300 40 0 0Dho Tarap 520 Tibetan 52 12 1 2Shipcho 100 Tibetan 6 3 0 0Tokyu 500 Tibetan 51 11 1 1Rigmo 300 Tibetan 25 10 1 1Pugmo 250 Tibetan 20 6 0 0Sahartara 1976 Magar 245 40 1 1Ranji 150 Gurung 18 4 0 0

TOTAL 12287 1597 300 20 30

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Footnotes






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Is it fate?






local remedies:

















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Nepal: A mixed methods study











jpaedsopen.bmj.com

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1

Neonatal mortality and child health in a remote rural area in Nepal:

A mixed methods study


Authors Affiliations:1; Charité University, Berlin2; University of Vienna


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2

Abstract

Objective: To assess neonatal and under five mortality and the health situation for children in






be unreliable.


visited ten randomly selected villages (plus one settlement) with approximately 12,000

inhabitants.

Methodology: Records of the number of deliveries, neonatal and under five deaths were


during the month prior to the investigation. 20 interviews were conducted about the cultural

perceptions of neonatal death and morbidity; in each village at least one interview was

undertaken.

Results: The population of the 10 villages (plus one settlement) under investigation was

12,287. 300 deliveries have taken place during the last 12 months before the study. There

were 30 children reported to have died; out of those 20 were in the neonatal period. This

reflects an estimated neonatal mortality rate in Dolpa district of 67/1000 live births (95% CI

41-101/1000) and an estimated under five mortality rate of 100/1000 (95% CI 70-140/1000).

In the previous month, out of 100 children surveyed there had been 11 cases of ALRI, seven

cases of diarrhoea, three cases of isolated malnutrition, and five cases of malnutrition

combined with ALRI or diarrhoea.







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Key-words



What is already known?

In spite of substantial improvements previous studies have shown considerable disparity in

neonatal and under 5 mortality in different parts of Nepal.

What this study adds?

There is under-reporting of neonatal mortality in the region.

There is a substantial need to increase appropriately trained health staff, who also need to

respond to the cultural context.

There is need for adequate health promotion to improve hygiene and to work on better


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4







Many parts of the country had been almost impossible to access until 60 years ago, and



Innovations may be observed with interest, but changes and adaptations are not the strength of












The problem


years the under five mortality decreased from 133 deaths per 100 live births in 1991 to 39

deaths per 1000 live births in 2016 (4,5) according to national data. Even neonatal mortality,

which has made the slowest progress globally, has decreased from 50 deaths per 1000 live

births in 1991 to 29 in 2016 (4,5). Nepal has successfully improved coverage of effective

interventions to prevent or treat the most important causes of child mortality through a variety


high coverage of six monthly vitamin A supplementation and deworming, the integrated



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However, access to health care and to community-based child health interventions varies. The




ways.




neonatal death and child mortality (9). Studies in 2000 in Mugu district (neighbouring district

of Dolpa) have reported an infant mortality as high as 201/1000 (10).



and injuries (11).

Rationale


to have quantitative estimations about neonatal and under five mortality, children's health



(6).

The aim of the study was to analyse the obstacles, and to contribute to finding ways to

improve the present situation in areas with limited access.

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Methodology

10 villages (clusters) were randomly selected. These included villages with different ethnic


the district headquarter Dunai with a mixed but mainly Chetri population and six other

villages, five inhabited by Tibetans and one by Gurung (13).











under the age of five were enrolled in the study.







diagnostic tool for protein-energy malnutrition. Regarding ALRI we confined the

definition to cough and fever, the assessment for fast breathing has been vague. For acute

watery diarrhoea we used the usual definition of more than three loose stools per day for

less than 14 days.

2. Neonatal and under five mortality.





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3. Cultural perceptions of newborn and child health (qualitative part).




accompanying health professional. The principles of discourse analysis were followed

(14). The participants were chosen as much as possible randomly, but partly also to

convenience, as some have been more eager to speak out than others. Consenting parents

were involved in a semi-structured interview about neonatal deaths, their views on child

health, the problems they faced and the actions they are and have been taking. We used a

semi-structured interview to understand: how the death of a newborn is perceived by the

family; whether common childhood diseases are treated or prevented using local

remedies; what solutions the community may propose to improve the child and newborn

health status. One to three interviews were taken in each of 10 villages, a total of 20

interviews. Qualitative interviews were conducted in Nepali or Tibetan by the

accompanying health assistant and then immediately transcribed in English. All interviews

were done in a private environment respecting the dignity of the participants and with

their full consent.















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Ethics



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9

Results

Childhood Morbidity

For the data on morbidity we mainly relied on the information provided by parents. In the 10


Parents of 11 out of 100 children surveyed reported an acute lower respiratory infection

during the previous month.

Parents of seven children out of 100 reported their child suffering from acute watery diarrhoea

during the previous month. Diarrhoea was more common in the Chetri (five cases) than in the

Tibetan population (two cases). In four cases there was a combination of malnourishment and


Eight children had malnutrition; in four cases there was a combination of malnutrition with

diarrhoea, in one case a combination of pneumonia and malnutrition at the time of

investigation. All cases of malnutrition were seen in the Chetri villages; in the Tibetan

villages no malnutrition was diagnosed.

One child suffering from malnutrition and ALRI had congenital heart disease. No other

disease was diagnosed for the children under investigation.





Estimated neonatal and childhood mortality



reflects an estimated neonatal mortality rate of 67/1000 (95% confidence interval 41-

101/1000).

The highest neonatal mortality appeared to be in Chetri villages in the southern part of Dolpa

with the exception of one village (Dangi Tara), where not a single death was reported (Table

1). A possible reason for the exception is better access to health facilities due to proximity to

the airport. There was general agreement that most deliveries take place at home without

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10

trained birth attendant and that neonatal deaths are usually not reported. Reasons for most of

the neonatal deaths could not be given.

10 children older than 28 days had died during last year, five were suffering from pneumonia,

and five were suffering from bloody diarrhoea. The under five mortality rate for the area of

study was estimated to be 100 per 1000 live births (95% CI 70-140/1000).

Interviews


Randomly we selected one to three women in each of the 10 villages, altogether 20 women.

They were asked about their perception of neonatal death and about any sickness of their

children as well as their approach for a solution.






The names of the mothers at the end of the interviews do not reflect their real names.





(Ditya, mother of two sons and one daughter)



was born I had to stay for nine days at home. It was winter and was very cold. The

baby got sick shortly after delivery. I was thinking to go to a doctor but I was told that

the cause of the fever is bhut (bad spirit, evil eye) and whatever happens would be

God’s will. After two weeks the baby died. Fortunately a year later I got pregnant

again and gave birth to a healthy son. My family was very happy.’

Sabitri (mother of two sons and two daughters)




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11


Dolma (mother of two sons)

How the main childhood diseases like ALRI’s and diarrhoeal diseases are prevented by local


their children.





Hara (mother of one son and three daughters)




still did not improve. Then I looked for our amchi (doctor practising traditional



Yangchen (mother of one daughter)

‘When my son was about two years old he had repeated attacks of diarrhoea. He

started to lose weight. After one to two months I thought he might die. We went to our

health post but the health worker was not present. So we performed a ceremony

(chakri) at our home. A few days later my son recovered and since then he hardly got

sick anymore.’

Goma (mother of one son)

Which solutions the community is proposing as prevention: The three women interviewed in

the district capital Dunai were satisfied with the service of the district hospital. They said that

most of the time nurses are present and are providing a proper service to patients.

Two women living close to Tapriza also appreciated the service provided by the health post

there.




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13

Discussion

In this study we were able to not only describe the newborn and child health status of children

in a remote, rural district in Nepal but also unpack the factors influencing mortality and

morbidity. We found that neonatal mortality was well above average for Nepal, while

morbidity patterns were similar to the rest of Nepal. Factors contributing to poor child health

status in this region were largely due to poor health systems and infrastructure, poor health

literacy, inadequately trained health workers, and exacerbated by socio-cultural factors

(4,8,15–18).

Respiratory infections were common in the colder regions inhabited by mainly Tibetans

whereas diarrhoea has been more common in the lower regions mainly inhabited by Chetris.



problem.


deaths are not reported. Deliveries are usually taking place at home and are attended by an


skilled.


been some in previous years. If finances are allowing a few pregnant mothers are going to

Kathmandu for delivery.


health.









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based on misconceptions, like medicine from tourists is ‘good medicine’. To go for medical

treatment to Kathmandu seemed to be also a question of social status and the dedication of

local nurses and the importance of medical knowledge and proper clinical examination have

been generally underestimated and the possibilities in the capital with CT and other expensive

procedures highly overestimated.



indication. The main reasons for observed improvements appear to be successful vaccination

campaigns and economic progress in some regions. On the other hand there is obvious lack of

ante- and postnatal care, home deliveries without the presence of skilled birth attendants are

still taking place in the majority of cases and there is lack of hygienic conditions as warm

water is hardly available.







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Limitations






elders.












(10).


education and lack of health promotion. Most deliveries still take place without a skilled birth



neonatal death as it interpreted as karma, as fate due to previous bad deeds, is one of the








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medicines are used indifferently and much funds are spent on often unnecessary referrals into

the main centres.



Aama programme, the female community health volunteer programme, the community-based


Health promotion efforts should focus on improving hygiene and better access to and

acceptance of quality health services.

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Acknowledgments



We also want to thank the health workers in Dolpa, who have been of tremendous help to

conduct the study and last not least the people of Dolpa, who have been supportive and






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Bibliography

1. Legatum Prosperity Index. Nepal. Legatum Prosper Index. 2016;

2. Pedersen S. Challenging Indoor Air Pollution in Nepal. Technical University, Denmark; 2009.

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5. World Bank. Mortality rate, under 5. The World Bank. 2019.

6. Ministry of Health. Nepal’s Every Newborn Action Plan Government of Nepal Ministry of Health. 2016.

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8. Ministry of Health. Nepal Demographic and Health Survey 2016 Key Indicators Report. Kathmandu; 2017.

9. Paudel M, Javanparast S, Dasvarma G, Newman L. Religio-cultural factors contributing to perinatal mortality and morbidity in mountain villages of Nepal: Implications for future healthcare provision. Dangal G, editor. PLoS One. 2018 Mar 15;13(3):e0194328.


11. WHO MCEE. MCEE-WHO. 2018.

12. Manang.com. Major ethnic groups in Nepal, Sherpa, Gurung, Thakali, Tamang, Rai, Limbu, Tharu, Newar, Dolpo - pa, Brahman / Chhetri, Chepang, MagarManagi. 2015.

13. Statistics CB of. National Population and Housing Census 2011. 2014.

14. Shanthi A, Wah LK, Lajium D. Discourse Analysis as a Qualitative Approach to Study Information Sharing Practice in Malaysian Board Forums. Int J E-Learning Pract. 2015;2(November 2016):159–69.

15. UNICEF. Diarrhoeal disease - UNICEF DATA. 2018.


17. Banstola A, Banstola A. The epidemiology of hospitalization for pneumonia in children under five in the rural western region of Nepal: a descriptive study. PLoS One. 2013;8(8):e71311.

18. Sathian B, De A, Simkhada P, Malla K, Ghosh A, Basnet S, et al. Time Trend of

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Pneumonia in under Five Children of Nepal. Am J Public Heal Res Vol 3, 2015, Pages 27-30. 2015 Jul 1;3(4A):27–30.

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Table 1: Neonatal and under 5 deaths

Village Population Ethnic Under 5 population Deliveries Neon. deaths Under 5 deaths

Dunai 2592 Chetri (mainly) 310 75 5 8Tripurakot 2697 Chetri 420 75 8 12Raha 923 Chetri 150 24 3 5Dangi Tara 2279 Chetri 300 40 0 0

Dho Tarap 520 Tibetan 52 12 1 2Shipcho 100 Tibetan 6 3 0 0Tokyu 500 Tibetan 51 11 1 1Rigmo 300 Tibetan 25 10 1 1Pugmo 250 Tibetan 20 6 0 0

Sahartara 1976 Magar 245 40 1 1Ranji 150 Gurung 18 4 0 0

Chetri total 8491 1180 214 16 25Tibetan total 1670 154 42 3 4Others total 2126 263 44 1 1

TOTAL 12287 1597 300 20 30

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Is it fate?






local remedies:

















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1BMJ Paediatrics Open 2019;3:e000519corr1. doi:10.1136/bmjpo-2019-000519corr1

Open access

Correction: neonatal mortality and child health in a remote rural area in Nepal: a mixed methods study

Karki BK, Kittel G. Neonatal mortality and child health in a remote rural area in Nepal: a mixed methods study. BMJ Paediatrics Open 2019;3:e000519. doi: 10.1136/bmjpo-2019-000519

This article was previously published with an error.Correct Contributors statement is:Contributors: GK collected the data and has done the interviews, BK and GK did the

study design, GK has developed the section on methodology, BK and GK did the anal-ysis of the data and the interpretation of the data, BK and GK developed together the discussion as well as the summary and conclusion. Professor Trevor Duke (TD) served as senior academic adviser.

Correct affiliation for Bindu Kumari Karki is:Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin,

Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Tropical Medicine and International Health

Open access This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http:// creativecommons. org/ licenses/ by- nc/ 4. 0/.

© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.BMJ Paediatrics Open 2019;3:e000519corr1. doi:10.1136/bmjpo-2019-000519corr1

Correction

http://bmjopen.bmj.com/

http://creativecommons.org/licenses/by-nc/4.0/

http://crossmark.crossref.org/dialog/?doi=10.1136/bmjpo-2019-000519corr1&domain=pdf&date_stamp=2019-010-04