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Introduction: This is a one-year post-intervention study following an initiative to provide orientation to female community health volunteers (FCHVs) on postpartum family planning in Nepal. In light of positive results in the earlier post-intervention study, this study was designed to provide a more long-term perspective on sustainability by assessing the effect at one-year post-intervention. Methods: This mixed-methods study was conducted in January 2020 in Morang district, Nepal. We collected quantitative data from a knowledge assessment of FCHVs who had participated in the intervention on postpartum family planning, data on their community-based counseling coverage and through interviews with postpartum mothers in two selected hospitals. Qualitative data were collected through six key informant interviews with health providers and four focus group discussions with FCHVs involved in the intervention. We performed descriptive and multivariate analyses for quantitative data and thematic analysis for qualitative data. Results: In total, 206 FCHVs participated in the one-year post-intervention study with significant improvement in knowledge of postpartum family planning as compared to pre-intervention period. The adjusted odds ratios (AOR) for knowledge of the 5 key messages on postpartum family planning as compared to the pre-intervention period included 1) knowledge on postpartum family planning can be used immediately after birth (AOR = 18.1, P<0.001), 2) postpartum intra-uterine device (PPIUD) can provide protection up to 12 years (AOR = 2.9, P = 0.011), 3) mothers who undergo cesarean section can use PPIUD (AOR = 2.3, P<0.001), 4) PPIUD can be inserted immediately after birth (AOR = 6.2, P <0.001), and 5) women should go for follow-up immediately if the IUD strings are seen outside vulva (AOR = 2.0, P = 0.08). The FCHVs answering 4 or more questions correctly was 10 times higher (AOR = 10.1, P<0.001) at one-year post-intervention, whereas it was 25 times higher at immediate-post-test (AOR = 25.1, p<0.001) as compared to pre-intervention phase. The FCHVs had counseled 71% of the pregnant women (n = 538) within their communities at one-year post-intervention. The postpartum mothers in hospitals had a 2 times higher odds of being counseled by FCHVs during their pregnancy at one-year post-intervention (AOR = 1.8, P = 0.039) than in pre-intervention phase. The qualitative findings suggested a positive impression regarding the FCHV's involvement in postpartum family planning counseling in the communities, however, supervision and monitoring over a longer term was identified as a key challenge and that may influence sustainability of community-based and hospital-based postpartum family planning services. Conclusion: The FCHVs' knowledge and community-based activities on postpartum family planning remained higher than in the pre-intervention. However, it declined when compared to the immediate post-intervention period. We propose regular supervision and monitoring of the work of the FCHVs to sustain progress. [ABSTRACT FROM AUTHOR]

As part of a multisectoral response to gender-based violence (GBV), Nepal is testing the feasibility of having female community health volunteers (FCHVs) play a formal role in identifying GBV survivors and referring them to specialised services at health facilities. This study followed 116 FHCVs in Mangalsen municipality who attended a one-day orientation on GBV. Over the following year, data were collected from knowledge and attitude assessments of FCHVs, focus group discussions with FCHVs, and members of Mothers' Groups for Health. Most Significant Change stories were collected from FCHVs, in-depth interviews with stakeholders, and service statistics. Results show that the FCHVs' knowledge increased, attitudes changed, and confidence in addressing GBV grew. During the study period, FCHVs identified 1,253 GBV survivors and referred 221 of them to health facilities. In addition to assisting GBV survivors, FCHVs worked to prevent GBV by mediating conflicts and curbing harmful practices such as menstrual isolation. Stakeholders viewed FCHVs as a sustainable resource for identifying and referring GBV survivors to services, while women trusted them and looked to them for help. Results show that, with proper training and safety mechanisms, FCHVs can raise community awareness about GBV, facilitate support for survivors, and potentially help prevent harmful practices. [ABSTRACT FROM AUTHOR]

Background: Family planning services in the post-partum period, termed post-partum family planning (PPFP) is critical to cover the unmet need for contraception, especially when institutional delivery rates have increased. However, the intention to choose PPFP methods such as post-partum intrauterine devices (PPIUD) remains low in countries such as Nepal. Community health workers such as Female Community Health Volunteers (FCHVs) could play an important role in improving the service coverage of PPFP in Nepal. However, their knowledge of PPFP and community-based services related to PPFP remain unclear. This study aims to assess the effect on community-based PPFP services by improving FCHV's knowledge through orientation on PPFP.Methods: We conducted this mixed-methods study in Morang District in Nepal. The intervention involved orientation of FCHVs on PPFP methods. We collected quantitative data from three sources; via a survey of FCHVs that assessed their knowledge before and after the intervention, from their monthly reporting forms on counseling coverage of women at different stages of pregnancy from the communities, and by interviewing mothers in their immediate post-partum period in two selected hospitals. We also conducted six focus group discussions with the FCHVs to understand their perception of PPFP and the intervention. We performed descriptive and multivariable analyses for quantitative results and thematic analysis for qualitative data.Results: In total, 230 FCHVs participated in the intervention and their knowledge of PPFP improved significantly after it. The intervention was the only factor significantly associated with their improved knowledge (adjusted odds ratio = 24, P < 0.001) in the multivariable analysis. FCHVs were able to counsel 83.3% of 1872 mothers at different stages of pregnancy in the communities. In the two hospitals, the proportion of mothers in their immediate post-partum period whom reported they were counseled by FCHVs during their pregnancy increased. It improved from 7% before the intervention to 18.1% (P < 0.001) after the intervention. The qualitative findings suggested that the intervention improved their knowledge in providing PPFP counseling.Conclusion: The orientation improved the FCHV's knowledge of PPFP and their community-based counseling. Follow-up studies are needed to assess the longer term effect of the FCHV's role in improving community-based PPFP services. [ABSTRACT FROM AUTHOR]

Objective: To explore the perceptions of key stakeholders on different modalities of training and mentoring activities for healthcare providers of postpartum family planning and postpartum intrauterine devices (PPFP/PPIUD). Methods: In this qualitative study, data were collected from 40 participants in December 2017 via focus group discussions (FGD) and in‐depth interviews (IDI) in three hospitals implementing PPFP/PPIUD services and government line agencies in Nepal. Data were analyzed through content analysis and grouped into themes and categories. Results: The majority of participants reported that PPFP/PPIUD training and mentoring was useful and contributed to their professional development. Most found that on‐the‐job training (OJT) was more effective than group‐based training (GBT). Conclusion: Training and mentoring activities were perceived to be useful by health providers and OJT was the approach preferred by the majority. Further studies are necessary to explore the existing challenges and long‐term effects of each modality of training and mentoring on health providers' competency and attitudes and on the uptake of PPIUD by postpartum mothers. This qualitative study showed positive perceptions about postpartum family planning/postpartum intrauterine device training and mentoring activities among healthcare providers and key stakeholders in Nepal. [ABSTRACT FROM AUTHOR]

Background: Early first-trimester medical abortion (MA) service (≤ 63 days) has been provided by doctors and nurses under doctors' supervision since 2009 in Nepal. This paper assesses whether MA services provided by specifically trained and certified nurses and auxiliary nurse-midwives independently from doctors' supervision, is considered as satisfactory by women as those provided by doctors. Methods: The data come from a multi-center, randomized, controlled equivalence trial conducted between April 2009 and March 2010 in five district hospitals in Nepal. Women seeking MA were randomly assigned to doctors or nurses and auxiliary nurse-midwives(ANMs). Eligible women were administered 200 mg mifepristone orally followed by 800 µg misoprostol vaginally two days later by their assigned providers and followed up 10-14 days later. At the follow-up visit women's reported satisfaction with MA service they received was measured. Results: Of 1295 women screened for eligibility, 535 were randomly assigned to a doctor and 542 to a nurse or ANM. Nineteen women were lost-to-follow up in the former group and 27 were lost-to-follow up or did not complete the acceptability interview in the latter group. This study is, therefore, based on516womenin the doctor's group and 515 women in the nurse or ANM group. All women in the nurse or ANM group reported being satisfied or highly satisfied by MA compared to 99% in the doctor's group. Satisfaction was similar regardless of the type of provider; 38% among nurse or ANM and 35% among the doctor group were "highly satisfied", and 62% and 64%, respectively, were "satisfied". Women's experiences such as 'less than expected amount or duration of bleeding following MA', 'shorter than expected duration of the abortion process', and 'able to manage symptoms', were found to be associated with women's higher satisfaction with MA. Counseling and information on the method, potential complications of MA and post-abortion contraception was nearly universal. No statistically significant differences were found in the level of satisfaction by age, parity, marital status, education or occupation of women. Conclusions: Women's satisfaction with MA service provided by trained nurses or auxiliary nurse-midwives was similar to that provided by doctors. The findings, therefore, provide support for extending safe and accessible medical abortion services by government-trained nurses and auxiliary nurse midwives to women seeking early first trimester pregnancy termination. Trial registration: The trial was retrospectively registered with ClinicalTrials.gov (identifier: NCT01186302). Registered August 20, 2010. [ABSTRACT FROM AUTHOR]

Background: In Nepal, pre-eclampsia/eclampsia (PE/E) causes an estimated 21% of maternal deaths annually and contributes to adverse neonatal birth outcomes. Calcium supplementation has been shown to reduce the risk of PE/E for pregnant women and preterm birth. This study presents findings from a cost-effectiveness analysis of a pilot project, which provided calcium supplementation through the public sector to pregnant women during antenatal care for PE/E prevention as compared to existing PE/E management in Nepal. Methods: Economic costs were assessed from program and societal perspectives for the May 2012 to August 2013 analytic time horizon, drawing from implementing partner financial records and the literature. Effects were calculated as disability-adjusted life years (DALYs) averted for mothers and newborns. A decision tree was used to model the cost-effectiveness of three strategies delivered through the public sector: (i) calcium supplementation in addition to the existing standard of care (MgSO4); (ii) standard of care, and (iii) no treatment. Uncertainty was assessed using one- way and probabilistic sensitivity analyses in TreeAge Pro. Results: The costs to start-up calcium introduction in addition to MgSO4 were $44,804, while the costs to support ongoing program implementation were $72,852. Collectively, these values correspond to a program cost per person per year of $0.44. The calcium program corresponded to a societal cost per DALY averted of $25.33 ($25.22-29.50) when compared against MgSO4 treatment. Primary cost drivers included rate for facility delivery, costs associated with hospitalization, and the probability of developing PE/E. The addition of calcium to the standard of care corresponds to slight increases in effect and cost, and has a 84% probability of cost-effectiveness above a WTP threshold of $40 USD when compared to the standard of care alone. Conclusions: Calcium supplementation for pregnant mothers for prevention of PE/E provided with MgSO4 for treatment holds promise for the cost-effective reduction of maternal and neonatal morbidity and mortality associated with PE/E. The findings of this study compare favorably with other low-cost, high priority interventions recommended for South Asia. Additional research is recommended to improve the rigor of evidence available on the treatment strategies and health outcomes. [ABSTRACT FROM AUTHOR]

Background. The Government of Nepal is interested in preventing congenital rubella syndrome (CRS). Surveillance data were analyzed and studies conducted to assess the burden of rubella and CRS and aid in developing a rubella vaccination strategy. Methods. (1) Analysis of rubella cases reported through measles surveillance, 2004 - 2009; (2) in 2008, rubella seroprevalence among women 15 to 39 years of age was evaluated; and (3) in 2009, children attending a school for the deaf were examined for ocular defects associated with CRS. Results. From 2004-2009, there were 3,710 confirmed rubella cases and more than 95% of these cases were less than 15 years of age. Of 2,224 women of childbearing age (WCBA) tested for anti-rubella IgG, 2,020 (90.8%) were seropositive. Using a catalytic infection model, approximately 1,426 infants were born with CRS (192/100,000 live births) in 2008. Among 243 students attending a school for the deaf, 18 (7.4%) met the clinical criteria for CRS. Conclusions. Rubella and CRS were documented as significant public health problems in Nepal. A comprehensive approach is necessary, including introducing rubella vaccine in the routine program, assuring immunity among WCBA, strengthening routine immunization, integrating rubella surveillance with measles casebased surveillance, and establishing CRS surveillance. [ABSTRACT FROM AUTHOR]

Nepal is on target to meet the Millennium Development Goals for maternal and child health despite high levels of poverty, poor infrastructure, difficult terrain and recent conflict. Each year, nearly 35 000 Nepali children die before their fifth birthday, with almost two-thirds of these deaths occurring in the first month of life, the neonatal period. As part of a multi-country analysis, we examined changes for newborn survival between 2000 and 2010 in terms of mortality, coverage and health system indicators as well as national and donor funding. Over the decade, Nepal’s neonatal mortality rate reduced by 3.6% per year, which is faster than the regional average (2.0%) but slower than national annual progress for mortality of children aged 1–59 months (7.7%) and maternal mortality (7.5%). A dramatic reduction in the total fertility rate, improvements in female education and increasing change in skilled birth attendance, as well as increased coverage of community-based child health interventions, are likely to have contributed to these mortality declines. Political commitment and support for newborn survival has been generated through strategic use of global and national data and effective partnerships using primarily a selective newborn-focused approach for advocacy and planning. Nepal was the first low-income country to have a national newborn strategy, influencing similar strategies in other countries. The Community-Based Newborn Care Package is delivered through the nationally available Female Community Health Volunteers and was piloted in 10 of 75 districts, with plans to increase to 35 districts in mid-2013. Innovation and scale up, especially of community-based packages, and public health interventions and commodities appear to move relatively rapidly in Nepal compared with some other countries. Much remains to be done to achieve high rates of effective coverage of community care, and especially to improve the quality of facility-based care given the rapid shift to births in facilities. [ABSTRACT FROM PUBLISHER]

Objective: To record and analyze complication rates following postpartum intrauterine device (PPIUD) insertion in 48 hospitals in six countries: Sri Lanka, India, Nepal, Bangladesh, Tanzania, and Kenya.Methods: Healthcare providers were trained in counselling and insertion of PPIUD via a training-the-trainer model. Data were collected on methodology, timing, cadre of staff providing care, and number of insertions. Data on complications were collected at 6-week follow-up. Statistical analysis was performed to elucidate factors associated with increased expulsion and absence of threads.Results: From May 2014 to September 2017, 36 766 PPIUDs were inserted: 53% vaginal and 47% at cesarean delivery; 74% were inserted by doctors. Follow-up was attended by 52%. Expulsion and removal rates were 2.5% and 3.6%, respectively. Threads were not visible in 29%. Expulsion was less likely after cesarean insertion (aOR 0.33; 95% CI, 0.26-0.41), following vaginal insertion at between 10 minutes and 48 hours (aOR 0.59; 95% CI, 0.42-0.83), and when insertion was performed by a nurse (aOR 0.33; 95% CI, 0.22-0.50).Conclusion: PPIUD has low complication rates and can be safely inserted by a variety of trained health staff. Given the immediate benefit of the one-stop approach, governments should urgently consider adopting this model. [ABSTRACT FROM AUTHOR]

Objective: To examine the factors that positively influenced the likelihood of accepting provision of postpartum intrauterine devices (PPIUDs) across four countries: Sri Lanka, Nepal, Tanzania, and India.Methods: Healthcare providers were trained across 24 facilities in counselling and insertion of PPIUDs as part of a large multicountry study. Women delivered were asked to take part in a 15-minute face-to-face structured interview conducted by in-country data collection officers prior to discharge. Univariate analysis was performed to investigate factors associated with acceptance.Results: From January 2016 to November 2017, 6477 health providers were trained, 239 033 deliveries occurred, and 219 242 interviews were conducted. Of those interviewed, 68% were counselled on family planning and 56% on PPIUD, with 20% consenting to PPIUD. Multiple counselling sessions was the only factor resulting in higher consent rates (OR 1.30-1.39) across all countries. Odds ratios for women's age, parity, and cadre of provider counselling varied between countries.Conclusion: Consent for contraception, specifically PPIUD, is such a culturally specific topic and generalization across countries is not possible. When planning contraceptive policy changes, it is important to have an understanding of the sociocultural factors at play. [ABSTRACT FROM AUTHOR]

The article presents a study which investigates early medical abortion administration of midlevel health care providers. The randomised controlled equivalence trial was conducted to women who are eligible and decided for a medical abortion during their pregnancy of less than nine weeks in five rural districts in Nepal. The study shows that midlevel health-care providers with abortion care training and have additional medical abortion training can independently administer safe medical abortion.

Maternal mortality is falling in most of the world's countries, but, for 20 years, the United States has seen no reduction. Over this period, a dozen countries in various stages of development, all spending much less than the United States on health, achieved their United Nations' Millennium Development Goal of 2015 (Millennium Development Goal 5: improve maternal health), with substantial reductions in maternal mortality rates. To consider whether interventions successful in reducing global maternal mortality rates could help the United States to lower its rate, the American College of Obstetricians and Gynecologists, at the 2018 International Federation of Gynecology and Obstetrics' Rio de Janeiro World Congress, convened a panel of the presidents and representatives from five national societies with wide maternal mortality rate ranges and health expenditures and whose national societies had focused on reducing maternal mortality for Millennium Development Goal 5. They identified expanded access to reproductive health care, particularly contraception and safe abortion, as key interventions that had proven effective in decreasing maternal mortality rates worldwide.

Introduction: Nepal Society of Obstetricians and Gynecologists jointly with the Nepalese government and with the support from the International Federation of Obstetrics and Gynecology has implemented an initiative to institutionalize postpartum family planning services in selected major referral facilities of Nepal to address the gap of low uptake of postpartum family planning in Nepal. The aim of the study is to find the prevalence of the service coverage of postpartum contraception in the selected facilities., Methods: A descriptive cross-sectional study was conducted in seven major referral facilities across Nepal. Data were collected from the hospital records of all women who delivered in these facilities between October 2018 and March 2019. Ethical approval for this study was obtained from Nepal Health Research Council. Data analysis was done with SPSS version 23., Results: Among the 29,072 deliveries from all the facilities, postpartum family planning counseling coverage was 27,301 (93.9%). The prevalence of uptake of Postpartum Intrauterine Device is 1581 (5.4%) and female sterilization is 1830 (6.3%). In total 11387 mothers (52.2%) had the intention to choose a postpartum family planning method. However, 36% of mothers neither used nor had the intention to choose a postpartum family planning method., Conclusions: The coverage of Postpartum Intrauterine Device counseling service coverage in Nepal is higher in 2018 as compared to 2016-2017 and in other countries implementing Postpartum Intrauterine Device initiatives. However, the prevalence of service coverage of immediate Postpartum Family Planning methods, mainly Postpartum Intrauterine Device in 2018 is lower in Nepal as compared to 2016-2017, and other countries implementing Postpartum Intrauterine Device initiative. More efforts are needed to encourage mothers delivering in the facilities to use the postpartum family planning method.

Background: In Nepal, 54% of women have an unmet need for family planning within the 2 years following a birth. Provision of a long-acting and reversible contraceptive method at the time of birth in health facilities could improve access to postpartum family planning for women who want to space or limit their births. This paper examines the impact of an intervention that introduced postpartum contraceptive counseling in antenatal care and immediate postpartum intra-uterine device (PPIUD) insertion services following institutional delivery, with the intent to eventually integrate PPIUD counseling and insertion services as part of routine maternity care in Nepal., Methods: This study took place in six large tertiary hospitals. All women who gave birth in these hospitals in the 18-month period between September 2015 and March 2017 were asked to participate. A total of 75,587 women (99.6% consent rate) gave consent to be interviewed while in postnatal ward after delivery and before discharge from hospital. We use a stepped-wedge cluster randomized design with randomization of the intervention timing at the hospital level. The baseline data collection began prior to the intervention in all hospitals and the intervention was introduced into the hospitals in two steps, with first group of three hospitals implementing the intervention 3 months after the baseline had begun, and second group of three hospitals implementing the intervention 9 months after the baseline had begun. We estimate the overall effect using a linear regression with a wild bootstrap to estimate valid standard errors given the cluster randomized design. We also estimate the effect of being counseled on PPIUD uptake., Results: Our Intent-to-Treat analysis shows that being exposed to the intervention increased PPIUD counseling among women by 25 percentage points (pp) [95% CI: 14-40 pp], and PPIUD uptake by four percentage points [95% CI: 3-6 pp]. Our adherence-adjusted estimate shows that, on average, being counseled due to the intervention increased PPIUD uptake by about 17 percentage points [95% CI: 14-40 pp]., Conclusions: The intervention increased PPIUD counseling rates and PPIUD uptake among women in the six study hospitals. If counseling had covered all women in the sample, PPIUD uptake would have been higher. Our results suggest that providing high quality counseling and insertion services generates higher demand for PPIUD services and could reduce unmet need., Trial Registration: Trial registered on March 11, 2016 with ClinicalTrials.gov, NCT02718222 .

Background: The use of post-partum family planning (PPFP) methods such as post-partum intrauterine device (PPIUD) in general remains low despite its benefits for the women. The reasons or factors affecting the uptake and continuation of such PPFP methods in developing countries such as Nepal remains unclear. This qualitative research aims to explore the factors affecting PPIUD uptake and continuation related behaviors among post-partum mothers within 6 weeks of childbirth in Nepal., Methods: This qualitative study was conducted through 43 in-depth interviews among post-partum mothers who delivered in 3 selected hospitals in Nepal. Data were analyzed through content analysis using the theory of planned behavior (TPB) as the theoretical framework., Results: The themes and categories were structured around the three major components of the TPB on attitude, subjective norms, and behavioral control. Majority of the women in this study, irrespective of their behavioral outcome expressed a positive attitude towards PPIUD use. However, the women who expressed an unfavorable attitude towards PPIUD influenced their behavior to not choose or discontinue PPIUD. Subjective norms such as the family, peer, and societal influences against PPIUD negatively affected the women's intention and behavior related to PPIUD. Whereas, the positive influence of the health providers positively affected their behavior. Regarding the behavior control, women who had their own control over decisions tended to use PPIUD. However, external factors such as their husband's preference or medical conditions also played a prominent role in preventing many to use PPIUD despite their positive intentions., Conclusion: As suggested in TPB, this study shows that multiple factors that are interlinked affected the behaviors related to uptake and continuation of PPIUD. The attitude helped in s`haping intention but did not always lead to the behavioral outcome of PPIUD uptake and continuation. Subjective norms had a strong influence on both intention and behavior. Behavior control belief also had an important role in the outcome with respect to PPIUD uptake and continuation. Thus, a more layered, multidimensional and interlinked intervention is necessary to bring positive behavior changes related to PPIUD.

Background: Kangaroo mother care, an evidence based practice and a national policy for management of low birth weight newborns in Nepal, is not widely practiced. This implementation research study aimed to explore the consumer preference and acceptability of the traditional and a new ergonomic wrap on the continuation of kangaroo mother care in the facility and community following discharge., Methods: A mixed method feasibility study was done from May to October 2015. Ninety-six families of stable low birth weight newborns weighing 1800 to 2499 grams were counseled and taught to practice kangaroo mother care using both wraps. They were randomized into two groups of 48 with one group trying out the traditional wrap for the first six hours and the new wrap for the next six, and vice versa. Mothers were allowed to choose between the wraps for continuation of kangaroo mother care at the facility and post discharge. They were followed up telephonically weekly over 28 days postpartum to ascertain practice of kangaroo mother care. In-depth interviews with mothers (n = 12) and focus group discussions with health workers (n = 16) further evaluated the intervention. Descriptive statistics are presented for the quantitative part of the study., Results: Mothers in the two groups chose the new wrap with no significant difference (81.3% vs 89.6%, p = 0.24). Of the 96 randomized mothers, 85% chose the new wrap. During the hospital stay, six mothers dropped out and remaining 90 mothers who were discharged with the intention of continuing Kangaroo Mother Care, 78 and 12 mothers did so with the new and traditional wrap respectively. New wrap users (429.1 hours, 95% confidence interval [CI]: 351.7-470.3) performed skin-to-skin contact for an extra 77.4 hours overall than traditional wrap (351.7 hours, 95%CI: 259.3-444) users from first day to 28 day postpartum. Health workers and mothers reported positive experience with the new wrap as it was easy to wear without assistance, secure and flexible to move around in kangaroo mother care position., Conclusions: Involvement of mothers and families with provision of ergonomic wraps showed improvement in kangaroo mother care practice during hospital stay and at home., Competing Interests: The authors have declared that no competing interests exist.

Introduction: Neonatal sepsis causes high morbidity and mortality of newborns. The study aims to study the predictors and clinical, haematological and bacteriological factors of neonatal sepsis., Methods: A descriptive cross sectional study was conducted in a Neonatal Intensive Care Unit (NICU) of Paropakar Maternity and Women's Hospital in Kathmandu between October and December 2011. Demographic, obstetrics, clinical and microbiological data were studied for 300 neonates., Results: The NICU prevalence rate of sepsis was 37.12%. Early onset neonatal sepsis was common (91.39%) (P=0.000). Cesarean section (OR 1.95, 95% CI 1.15-3.31), apgar score<4 at 1 min (P=0.00) and <7 at 5 min of birth (P=0.00) predicted sepsis. Neonates with sepsis were more likely to present with hypothermia (OR 1.180, 95% CI 0.080-17.214), pustules (OR 2.188, 95% CI 0.110-43.465), dehydration (OR 3.040, 95% CI 0.170-54.361), diminished movement (OR 3.082, 95% CI 0.433-21.950) and bulging fontanels (OR 16.464, 95% CI 0.007-41495.430). Coagulase negative Staphylococcus spp. (CoNS) (21, 41.17%) was most common pathogen of neonatal sepsis. Variable antibiotic resistance patterns of isolates with emergence of meropenem resistance in Pseudomonas spp. and methicillin resistance in CoNS and S. aurues were noted. Mortality due to sepsis was highest (15, 8.06%) among total mortalities (21, 11.29%)., Conclusions: Delivery via cesarian section, apgar score<4 at 1 min, and <7 at 5 min predicted sepsis. Morbidity and mortality of neonatal sepsis was common in this setting and early maternal and neonatal interventions are required to address this issue.

Background: In March 2002, Nepal's Parliament approved legislation to permit abortion on request up to 12 weeks of pregnancy. Between 2004 and 2007, 176 comprehensive abortion care (CAC) service sites were established in Nepal, leading to a rise in safe, legal abortions. Though monitoring systems have been developed, reporting of complications has not always been complete or accurate. The purpose of this study was to report the frequency and type of abortion complications arising from CAC procedures in different types of facilities in Nepal., Methods: A total of 7,386 CAC clients from a sample of facilities across Nepal were enrolled over a three-month period in 2008. Data collection included an initial health questionnaire at the time of abortion care and a follow-up questionnaire assessing complications, administered two weeks after the abortion procedure. A total of 7,007 women (95%) were successfully followed up. Complication rates were assessed overall and by facility type. Multivariable logistic regression was used to assess the association between experiencing a complication and client demographic and facility characteristics., Results: Among the 7,007 clients who were successfully followed, only 1.87% (n = 131) experienced signs and symptoms of complications at the two-week follow up, the most common being retained products of conception (1.37%), suspected sepsis (0.39%), offensive discharge (0.51%) and moderate bleeding (0.26%). Women receiving care at non-governmental organization (NGO) facilities were less likely to experience complications than women at government facilities, adjusting for individual and facility characteristics (AOR = 0.18; 95% CI: 0.08-0.40). Compared to women receiving CAC at 4-5 weeks gestation, women at 10-12 weeks gestation were more likely to experience complications, adjusting for individual and facility characteristics (AOR = 4.21; 95% CI: 1.38-12.82)., Conclusions: The abortion complication rate in Nepali CAC facilities is low and similar to other settings; however, significant differences in complication rates were observed by facility type and gestational age. Interventions such as supportive supervision to improve providers' uterine evacuation skills and investment in equipment for infection control may lower complication rates in government facilities. In addition, there should be increased focus on early pregnancy detection and access to CAC services early in pregnancy in order to prevent complications.

Background: Recent trials of chlorhexidine cord cleansing have employed aqueous solution applied with cotton swabs. Care-takers may prefer gel, resulting in better compliance when implemented at large scale. We examined whether a guar-gum-thickened formulation was at least as efficacious as aqueous in reducing periumbilical flora., Methods: Newborns (n = 694) from normal deliveries at a hospital in Kathmandu were randomly allocated to cord cleansing with either gel or aqueous chlorhexidine, applied by finger. Immediately before and 24 hours after cleansing, periumbilical swabs were collected and cultured. The primary outcome was periumbilical colonization at 24 hours. Household-level acceptability and ease of use in a rural setting where most deliveries are not attended by health workers were assessed by providing 61 women with either gel or aqueous formulations and following up on their experience using the products., Results: Babies allocated to gel and aqueous chlorhexidine were comparable on a range of variables measured at baseline. At 24 hours postapplication, 4.6% (15 of 327) of cultures were positive in the gel group and 10.7% (35 of 326) in the aqueous group. The absolute difference in rates (gel minus aqueous) was -6.1% (95% CI: -10.2%, -2.1%). The acceptability study found that satisfaction and compliance were high for both; use of either largely displaced the traditional use of oil-based mixtures. Overall, there was a preference for gel., Conclusions: The gel formulation was not inferior to aqueous and gel reduced bacterial colonization to a greater degree. A gel formulation might be considered in future research or program settings where chlorhexidine cleansing of the cord is being evaluated or promoted.