Publications by authors named "Rajendra Karkee"

47 Publications

Prevalence and determinants of non-communicable disease risk factors among adult population of Kathmandu.

PLoS One 2021 8;16(9):e0257037. Epub 2021 Sep 8.

Faculty of School of Public Health and Community Medicine, B.P. Koirala Institute of Health Sciences, Dharan, Nepal.

Background: According to WHO, the deaths due to NCDs in Nepal have soared from 60% of all deaths in 2014 to 66% in 2018. The study assessed the prevalence and determinants of non-communicable disease risk factors among adult population of Kathmandu.

Materials And Methods: A community based cross-sectional study was conducted from September 2019 to February 2020 among 18-69 years adults residing in municipalities of Kathmandu district. Multi-stage random sampling technique was used to select 245 subjects who were interviewed using WHO NCD STEPS instrument. Chi-square test and logistic regression analysis were done to explore the determinants of NCD risk factors.

Results: The prevalence of current smoking, alcohol consumption, low intake of fruits and vegetables and low physical activity was found to be 22%, 31%, 93.9% and 10.2% respectively. More than half (52.2%) of the participants were overweight or obese and the prevalence of raised blood pressure was 27.8%. Smoking was associated significantly with male gender (AOR = 2.37, CI: 1.20-5.13) and respondents with no formal schooling (AOR: 4.33, CI: 1.50-12.48). Similarly, the odds of alcohol consumption were higher among male gender (AOR: 2.78, CI: 1.47-5.26), people who were employed (AOR: 2.30, CI: 1.13-4.82), and those who belonged to Chhetri (AOR: 2.83, CI: 1.19-6.72), Janajati (AOR: 6.18, CI: 2.74-13.90), Dalit and Madhesi, (AOR: 7.51, CI: 2.13-26.35) ethnic groups. Furthermore, respondents who were aged 30-44 years (AOR: 5.15, CI: 1.91-13.85) and 45-59 years (AOR: 4.54 CI: 1.63-12.66), who were in marital union (AOR: 3.39, CI: 1.25-9.13), and who belonged to Janajati (AOR: 3.37, CI: 1.61-7.04), Dalit and Madhesi (AOR: 4.62, CI: 1.26-16.86) ethnic groups were more likely to be associated with overweight or obesity. Additionally, the odds of raised blood pressure were higher among people who were of older age (AOR: 6.91, CI: 1.67-28.63) and those who belonged to Janajati ethnic group (AOR: 3.60, CI: 1.46-8.87) after multivariate analysis.

Conclusion: The findings of the study highlighted high prevalence of behavioral and metabolic risk factors, which varied on different socio-demographic grounds. Thus, population specific health promotion interventions centered on public health interests is recommended to reduce risk factors of NCDs.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0257037PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8425558PMC
September 2021

Basic emergency obstetric and newborn care service availability and readiness in Nepal: Analysis of the 2015 Nepal Health Facility Survey.

PLoS One 2021 21;16(7):e0254561. Epub 2021 Jul 21.

School of Public Health and Community Medicine, BP Koirala Institute of Health Sciences, Dharan, Nepal.

Background: Achieving maternal and newborn related Sustainable Development Goals targets is challenging for Nepal, mainly due to poor quality of maternity services. In this context, we aim to assess the Basic Emergency Obstetric and Newborn Care (BEmONC) service availability and readiness in health facilities in Nepal by analyzing data from Nepal Health Facility Survey (NHFS), 2015.

Methods: We utilized cross-sectional data from the nationally representative NHFS, 2015. Service availability was measured by seven signal functions of BEmONC, and service readiness by the availability and functioning of supportive items categorized into three domains: staff and guidelines, diagnostic equipment, and basic medicine and commodities. We used the World Health Organization's service availability and readiness indicators to estimate the readiness scores. We performed a multiple linear regression to identify important factors in the readiness of the health facilities to provide BEmONC services.

Results: The BEmONC service readiness score was significantly higher in public hospitals compared with private hospitals and peripheral public health facilities. Significant factors associated with service readiness score were the facility type (14.69 points higher in public hospitals, P<0.001), number of service delivery staff (2.49 points increase per each additional delivery staff, P<0.001), the service hours (4.89 points higher in facilities offering 24-hour services, P = 0.01) and status of periodic review of maternal and newborn deaths (4.88 points higher in facilities that conducted periodic review, P = 0.043).

Conclusions: These findings suggest that BEmONC services in Nepal could be improved by increasing the number of service delivery staff, expanding service hours to 24-hours a day, and conducting periodic review of maternal and newborn deaths at health facilities, mainly in the peripheral public health facilities. The private hospitals need to be encouraged for BEmONC service readiness.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0254561PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8294533PMC
July 2021

Intersectional (in) equities in contact coverage of maternal and newborn health services in Nepal: insights from a nationwide cross-sectional household survey.

BMC Public Health 2021 06 9;21(1):1098. Epub 2021 Jun 9.

School of Public Health, Faculty of Medicine, University of Queensland, Brisbane, Australia.

Background: Persistent inequities in coverage of maternal and newborn health (MNH) services continue to pose a major challenge to the health-care system in Nepal. This paper uses a novel composite indicator of intersectional (dis) advantages to examine how different (in) equity markers intersect to create (in) equities in contact coverage of MNH services across the continuum of care (CoC) in Nepal.

Methods: A secondary analysis was conducted among 1978 women aged 15-49 years who had a live birth in the two years preceding the survey. Data were derived from the Nepal Demographic and Health Survey (NDHS) 2016. The three outcome variables included were 1) at least four antenatal care (4ANC) visits, 2) institutional delivery, and 3) postnatal care (PNC) consult for newborns and mothers within 48 h of childbirth. Independent variables were wealth status, education, ethnicity, languages, residence, and marginalisation status. Intersectional (dis) advantages were created using three socioeconomic variables (wealth status, level of education and ethnicity of women). Binomial logistic regression analysis was employed to identify the patterns of (in) equities in contact coverage of MNH services across the CoC.

Results: The contact coverage of 4ANC visits, institutional delivery, and PNC visit was 72, 64, and 51% respectively. Relative to women with triple disadvantage, the odds of contact coverage of 4ANC visits was more than five-fold higher (Adjusted Odds Ratio (aOR) = 5.51; 95% CI: 2.85, 10.64) among women with triple forms of advantages (literate and advantaged ethnicity and higher wealth status). Women with triple advantages were seven-fold more likely to give birth in a health institution (aOR = 7.32; 95% CI: 3.66, 14.63). They were also four times more likely (aOR = 4.18; 95% CI: 2.40, 7.28) to receive PNC visit compared to their triple disadvantaged counterparts.

Conclusions: The contact coverage of routine MNH visits was low among women with social disadvantages and lowest among women with multiple forms of socioeconomic disadvantages. Tracking health service coverage among women with multiple forms of (dis) advantage can provide crucial information for designing contextual and targeted approaches to actions towards universal coverage of MNH services and improving health equity.
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http://dx.doi.org/10.1186/s12889-021-11142-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8190849PMC
June 2021

Factors associated with low back pain among construction workers in Nepal: A cross-sectional study.

PLoS One 2021 1;16(6):e0252564. Epub 2021 Jun 1.

Department of Public Health, Kathmandu University School of Medical Sciences, Dhulikhel, Nepal.

Background: Low back pain (LBP) is the commonest cause of disability throughout the world. This study aimed to determine the prevalence and factors associated with LBP among the construction workers in Nepal.

Methods: A community-based cross-sectional study was conducted among the construction workers working in Banepa and Panauti municipalities of Kavre district, from September 2019 to February 2020. Data was collected purposively by face-to-face interview from 402 eligible participants from the both municipalities using semi-structured questionnaire. Mobile-based data collection was done using KoboCollect. Data were exported to and analysed using R-programming software (R-3.6.2). Univariate and multivariate logistic regressions were performed. All tests were two tailed and performed at 95% confidence interval (CI).

Result: One-year prevalence of LBP among construction workers were 52.0% (95%CI: 47.0-57.0). The higher odds of LBP was reported among females [adjusted odds ratio (aOR) = 2.42; 95%CI: 1.12-5.23], those living below poverty-line (aOR = 2.35; 95%CI: 1.32-4.19), participants with more than five years of work experience (aOR = 1.66; 95%CI: 1.01-2.73) and those with intermediate sleep quality (aOR = 2.06; CI: 1.03-4.11). About 80.0% of construction workers with LBP never seek healthcare services due to: a) time constraints (90.9%), b) financial constraints (18.1%) and c) fear of losing wages on seeking healthcare services (40.9%). The majority of the participants (94.8% among those without LBP and 72.3% among those with LBP) did nothing to prevent or manage LBP.

Conclusion: The prevalence of LBP in the past one year was high among construction workers where majority of workers never did anything to prevent or manage LBP. Therefore, the public health professionals should set up the health promotion, education, and interventions aimed at increasing awareness on preventive techniques and predisposing factors of LBP.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0252564PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8168885PMC
June 2021

Who are dying and why? A case series study of maternal deaths in Nepal.

BMJ Open 2021 05 13;11(5):e042840. Epub 2021 May 13.

Mother and Infant Research Activities, Kathmandu, Nepal.

Objectives: To identify delays and associated factors for maternal deaths in Nepal.

Design: A cross-sectional case series study of maternal deaths. An integrated verbal and social autopsy tool was used to collect quantitative and qualitative information regarding three delays. We recorded death accounts and conducted social autopsy by means of community Focus Group Discussions for each maternal death; and analysed data by framework analysis.

Setting: Sixty-two maternal deaths in six districts in three provinces of Nepal.

Results: Nearly half of the deceased women (45.2%) were primiparous and one-third had no formal education. About 40% were from Terai/Madhesi and 30.6% from lower caste. The most common place of death was private hospitals (41.9%), followed by public hospitals (29.1%). Nearly three-fourth cases were referred to higher health facilities and median time (IQR) of stay at the lower health facility was 120 (60-180) hours. Nearly half of deaths (43.5%) were attributable to more than one delay while first and third delay each contributed equally (25.8%). Lack of perceived need; perceived cost and low status; traditional beliefs and practices; physically inaccessible facilities and lack of service readiness and quality care were important factors in maternal deaths.

Conclusions: The first and third delays were the equal contributors of maternal deaths. Interventions related to birth preparedness, economic support and family planning need to be focused on poor and marginalised communities. Community management of quick transportation, early diagnosis of pregnancy risks, accommodation facilities near the referral hospitals and dedicated skilled manpower with adequate medicines, equipment and blood supplies in referral hospitals are needed for further reduction of maternal deaths in Nepal.
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http://dx.doi.org/10.1136/bmjopen-2020-042840DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8126278PMC
May 2021

Policies and actions to reduce maternal mortality in Nepal: perspectives of key informants.

Sex Reprod Health Matters 2021 ;29(2):1907026

Executive Director, Mother and Infant Research Activities (MIRA), Kathmandu, Nepal.

Nepal made impressive progress in reducing maternal mortality until 2015. Since then, progress has stagnated, coinciding with Nepal's transition to a federation with significant devolution in health management. In this context, we conducted key informant interviews (KII) to solicit perspectives on policies responsible for the reduction in maternal mortality, reasons for the stagnation in maternal mortality, and interventions needed for a faster decline in maternal mortality. We conducted 36 KIIs and analysed transcripts using standard framework analysis methods. The key informants identified three policies as the most important for maternal mortality reduction in Nepal: the Safe Motherhood Policy, Skilled Birth Attendant Policy, and Safe Abortion Policy. They opined that policies were adequate, but implementation was weak and ineffective, and strategies needed to be tailored to the local context. A range of health system factors, including poor quality of care, were identified by key informants as underlying the stagnation in Nepal's maternal mortality ratio, as well as a few demand-side aspects. According to key informants, to reduce maternal deaths further Nepal needs to ensure that the current family planning, birth preparedness, financial incentives, free delivery services, abortion care, and community post-partum care programmes reach marginalised and vulnerable communities. Facilities offering comprehensive emergency obstetric care need to be accessible, and in hill and mountain areas, access could be supported by establishing maternity waiting homes. Social accountability can be strengthened through social audits, role models, and empowerment of health and management committees.
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http://dx.doi.org/10.1080/26410397.2021.1907026DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8032335PMC
January 2021

How Does Public Knowledge, Attitudes, and Behaviors Correlate in Relation to COVID-19? A Community-Based Cross-Sectional Study in Nepal.

Front Public Health 2020 14;8:589372. Epub 2021 Jan 14.

BP Koirala Institute of Health Science, Dharan, Nepal.

The COVID-19 pandemic has created a global health emergency requiring an effective public health response including citizen's roles in preventing spread and controlling the pandemic. Little is known about public knowledge, beliefs and behaviors in-relation to the pandemic in Nepal. This study aims to assess knowledge, attitude and practices (KAP) toward COVID-19 among the general public and to identify associated factors. A cross-sectional survey was conducted between May-June 2020 with a sample of 645, recruited from 26 hospitals across Nepal. We conducted telephone interviews using a semi-structured questionnaire related to KAP regarding COVID-19. -test and one-way ANOVA was conducted to determine group differences for socio-demographic variables. Linear regression and correlational analysis were performed to identify associated factors and measure strength and direction of relationships. Overall mean scores for knowledge, attitude and practice were 11.6 (SD 4.5), 2.7 (SD 1.8), and 9.9 (SD 1.93) respectively, but differed by socio-demographic characteristics. Positive but weak linear correlations were observed between knowledge-practice ( = 0.19, < 0.01) and attitude-practice ( = 0.08, < 0.05). The relationship between knowledge and education was fairly strong ( = 0.34, < 0.01). Province, place of residence, ecological area, age, gender and caste/ethnicity were also significantly associated with KAP score of participants. The study found varying degrees of correlation between Knowledge, Attitude and Practice that may increase as the pandemic evolves in Nepal. Knowledge and level of education had positive associations with attitude and adherence to precautionary measures. The findings suggest a need for targeted community awareness interventions for the most vulnerable populations, men, those with no school education, the elderly and people living in rural areas.
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http://dx.doi.org/10.3389/fpubh.2020.589372DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7842277PMC
February 2021

Providing maternal health services during the COVID-19 pandemic in Nepal.

Lancet Glob Health 2020 10 10;8(10):e1243-e1244. Epub 2020 Aug 10.

Nossal Institute for Global Health, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia.

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http://dx.doi.org/10.1016/S2214-109X(20)30350-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7417156PMC
October 2020

A Cross-Sectional Survey of Contraceptive Use and Birth Spacing Among Multiparous Women in Eastern Nepal.

Asia Pac J Public Health 2020 Mar-Apr;32(2-3):91-95. Epub 2020 Mar 23.

B.P. Koirala Institute of Health Sciences, Dharan, Nepal.

Despite the known benefits of the use of contraceptives, notably birth spacing, the use of contraceptives in Nepal has remained stagnant since 2006. The purpose of this article is to assess the knowledge and use of contraceptives, and to ascertain preceding interbirth spacing in an eastern plain district of Nepal. A cross-sectional survey was completed on 406 multiparous women aged 18 to 49 years to collect data via structured questionnaires in Jhapa district of Nepal. The majority of the participants (96.1%) had knowledge of at least one modern contraceptive: injectable and oral contraceptives were the most common. Female sterilization was the most commonly used method of contraception. The median birth spacing was 41.5 months, and the majority of participants (79.1%) had preceding interbirth spacing greater than 24 months. The average preferred birth spacing was 51.3 months, and about half of the participants said that 60 months was the appropriate birth spacing. Though knowledge of contraceptives use is almost universal in this population, the use is still low. The preferred birth spacing is longer than the actual birth spacing, signifying an unmet need of contraception.
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http://dx.doi.org/10.1177/1010539520912117DOI Listing
July 2020

Social determinants of health affecting utilisation of routine maternity services in Nepal: a narrative review of the evidence.

Reprod Health Matters 2018 Nov 7;26(54):32-46. Epub 2018 Nov 7.

b Associate Professor, School of Public Health and Community Medicine , BP Koirala Institute of Health Sciences , Dharan , Nepal.

Nepal has one of the highest maternal and neonatal mortality rates among low- and middle-income countries. Nepal's health system focuses on life-saving interventions provided during the antenatal to postpartum period. However, the inequality in the uptake of maternity services is of major concern. This study aimed to synthesise evidence from the literature regarding the social determinants of health on the use of maternity services in Nepal. We conducted a structured narrative review of studies published from 1994 to 2016. We searched five databases: PubMed; CINAHL; EMBASE; ProQuest and Global Index Medicus using search terms covering four domains: access and use; equity determinants; routine maternity services and Nepal. The findings of the studies were summarised using the World Health Organization's Social Determinants of Health framework. A total of 59 studies were reviewed. A range of socio-structural and intermediary-level determinants was identified, either as facilitating factors, or as barriers, to the uptake of maternity services. These determinants were higher socioeconomic status; education; privileged ethnicities such as Brahmins/Chhetris, people following the Hindu religion; accessible geography; access to transportation; family support; women's autonomy and empowerment; and a birth preparedness plan. Findings indicate the need for health and non-health sector interventions, including education linked to job opportunities; mainstreaming of marginalised communities in economic activities and provision of skilled providers, equipment and medicines. Interventions to improve maternal health should be viewed using a broad 'social determinants of health' framework.
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http://dx.doi.org/10.1080/09688080.2018.1535686DOI Listing
November 2018

Implications of methodological differences in measuring the rates of exclusive breastfeeding in Nepal: findings from literature review and cohort study.

BMC Pregnancy Childbirth 2016 12 12;16(1):389. Epub 2016 Dec 12.

School of Public Health, Curtin University, Perth, Australia.

Background: Correct measurement and continuous monitoring of exclusive breastfeeding are essential to promote exclusive breastfeeding. Measuring exclusive breastfeeding is a complex issue as rates can vary according to the definition, measurement period, questions asked, and infant's age. This article reviewed the methodology of reporting exclusive breastfeeding in Nepal, and compared exclusive breastfeeding rates using data from a cohort study undertaken in western Nepal.

Methods: A literature review was first conducted on studies published during 2000-2014. In our cohort study, 735 mother-infant pairs were recruited within the first month postpartum and followed up during the fourth and sixth months.

Results: The majority of studies in Nepal, including national surveys, used the World Health Organization (WHO) recommended definition (only breastmilk with the exception of medicine and vitamin syrup), and the most common measurement period was a 24-h recall. Our data demonstrated that the exclusive breastfeeding rate during the sixth month was 8.9% using the recall-since-birth method but was 18.7% using the 24-h recall method. Substantial differences in rates were also found during the first (66.3% vs 83.9%) and fourth months (39.2% vs 61.1%).

Conclusion: We found that recent studies reporting exclusive breastfeeding in Nepal varied considerably in methodology. The most commonly used measurement, the 24-h recall, leads to over-estimation of the prevalence of exclusive breastfeeding when compared to the recall-since-birth method. A common standard of reporting exclusive breastfeeding is clearly needed for evidence-based decision making.
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http://dx.doi.org/10.1186/s12884-016-1180-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5154002PMC
December 2016

Birth Spacing of Pregnant Women in Nepal: A Community-Based Study.

Front Public Health 2016 19;4:205. Epub 2016 Sep 19.

School of Public Health, Curtin University , Perth, WA , Australia.

Background: Optimal birth spacing has health advantages for both mother and child. In developing countries, shorter birth intervals are common and associated with social, cultural, and economic factors, as well as a lack of family planning. This study investigated the first birth interval after marriage and preceding interbirth interval in Nepal.

Methods: A community-based prospective cohort study was conducted in the Kaski district of Nepal. Information on birth spacing, demographic, and obstetric characteristics was obtained from 701 pregnant women using a structured questionnaire. Logistic regression analyses were performed to ascertain factors associated with short birth spacing.

Results: About 39% of primiparous women gave their first child birth within 1 year of marriage and 23% of multiparous women had short preceding interbirth intervals (<24 months). The average birth spacing among the multiparous group was 44.9 (SD 21.8) months. Overall, short birth spacing appeared to be inversely associated with advancing maternal age. For the multiparous group, Janajati and lower caste women, and those whose newborn was female, were more likely to have short birth spacing.

Conclusion: The preceding interbirth interval was relatively long in the Kaski district of Nepal and tended to be associated with maternal age, caste, and sex of newborn infant. Optimal birth spacing programs should target Janajati and lower caste women, along with promotion of gender equality in society.
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http://dx.doi.org/10.3389/fpubh.2016.00205DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5027200PMC
September 2016

NGOs, Foreign Aid, and Development in Nepal.

Front Public Health 2016 24;4:177. Epub 2016 Aug 24.

School of Public Health, Curtin University , Perth, WA , Australia.

The number of non-governmental organizations (NGOs) working in Nepal has grown significantly since the 1990s due to a range of factors. A total of 39,759 NGOs and 189 international non-governmental organizations were registered in Nepal between 1977 and 2014 in various sectors, including health, agriculture, poverty alleviation, and good governance. Despite thousands of NGOs and significant amounts of foreign aid, Nepal remains one of the poorest countries in South Asia. The case of Nepal indicates that aid and donor support alone are insufficient for sustained development.
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http://dx.doi.org/10.3389/fpubh.2016.00177DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4995364PMC
September 2016

The supplemental use of infant formula in the context of universal breastfeeding practices in Western Nepal.

BMC Pediatr 2016 05 21;16:68. Epub 2016 May 21.

School of Public Health, Curtin University, Perth, Australia.

Background: While the initiation of breastfeeding is universal in Nepal, little has been reported on formula feeding practices. This study aimed to report the prevalence of, and factors associated with, the use of infant formula as supplementary feeds in the Western region of Nepal.

Methods: A community-based cohort study was conducted to collect infant feeding information among 735 postpartum mothers using structured questionnaires. Complete formula feeding data were collected from 711 women in the first, fourth and sixth month postpartum. Factors independently associated with formula feeding were investigated using multiple logistic regression.

Results: All mothers were breastfeeding their infants at the time of recruitment. The prevalence of formula feeding was 7.5 % in the first month and 17 % in the sixth month. About a quarter of mothers (23.8 %) reported providing infant formula at least once during the first six months of life. Infant formula was used commonly as top-up food. Stepwise logistic regression showed that infants born to families residing in urban areas (adjusted odds ratio (aOR): 2.14; 95 % confidence interval (CI): 1.37 to 3.33), mothers with higher education (aOR: 2.08; 95 % CI: 1.14 to 3.80), and infants born by caesarean section (aOR: 1.96; 95 % CI: 1.21 to 3.18) were at greater risk of formula feeding.

Conclusion: The current findings indicate that health workers should support mothers to initiate and continue exclusive breastfeeding particularly after caesarean deliveries. Furthermore, urban health programs in Nepal should incorporate breastfeeding programs which discourage the unnecessary use of formula feeding. The marketing of formula milk should be monitored more vigilantly especially in the aftermath of the April 2015 earthquakes or other natural disasters.
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http://dx.doi.org/10.1186/s12887-016-0602-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4875692PMC
May 2016

Epidemiology of road traffic injuries in Nepal, 2001-2013: systematic review and secondary data analysis.

BMJ Open 2016 Apr 15;6(4):e010757. Epub 2016 Apr 15.

School of Public Health, Curtin University, Perth, Western Australia, Australia.

Objective: To investigate the epidemiology of road traffic injury (RTI) in Nepal for the period 2001-2013.

Methods: 2 approaches, secondary data analysis and systematic literature review, were adopted. RTI data were retrieved from traffic police records and analysed for the incidence of RTI. Electronic databases were searched for published articles that described the epidemiology of RTI in Nepal.

Results: A total of 95,902 crashes, 100,499 injuries and 14,512 deaths were recorded by the traffic police over the 12-year period, 2001-2013. The mortality rate increased from 4/100,000 population in 2001-2002 to 7/100,000 population in 2011-2012. There were relatively more reported crashes yet fewer deaths in Kathmandu valley than the rest of the country. Of the 20 articles related to RTI, only 11 articles met the eligibility criteria, but these were mainly descriptive case series or cross-sectional hospital-based studies. The majority of RTI were reported to occur among motorcyclists and pedestrians, in males, and in the age group 20-40 years. The common sites of injury were lower and upper extremities. Only 3 articles mentioned possible causes of accidents that include pedestrian road behaviour, alcohol consumption and improper bus driving.

Conclusions: Nepal suffers a heavy burden of RTI, with higher fatalities on highways out of Kathmandu valley caused by bus crashes in hilly districts. The majority of published studies on RTI are descriptive and hospital based, indicating the need for more thorough investigation of causes of RTI and systematic recording of crashes for the development of effective interventions.
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http://dx.doi.org/10.1136/bmjopen-2015-010757DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4838689PMC
April 2016

Adverse obstetric symptoms and rural-urban difference in cesarean delivery in Rupandehi district, Western Nepal: a cohort study.

Reprod Health 2016 Mar 1;13:17. Epub 2016 Mar 1.

School of Public Health, Curtin University, Perth, WA, Australia.

Background: The burden of maternal morbidity is high in developing countries including Nepal. This study investigated obstetric complications and rural-urban difference in cesarean delivery rate in Western Nepal.

Methods: A community-based cohort study was conducted in the Rupandehi district of Western Nepal during January-October, 2014, by interviewing 735 mothers within one month postpartum. The prevalence of obstetric complications was reported via frequency distribution, while factors associated with cesarean delivery were assessed using logistic regression analysis.

Results: The prevalence of adverse obstetric symptoms during antenatal, intranatal and postnatal periods were 19.7%, 27.8% and 21.6%, respectively. In total, 81 (11.0%) mothers reported having stillbirths. The cesarean delivery rate was 14.1% overall but was four times higher in the urban (23.0%) than in the rural areas (5.8%). Prolonged labor (19.0%) and heavy bleeding (16.7%) were common among rural women. Logistic regression analysis confirmed that cesarean section was more likely for mothers residing in urban areas than in rural areas (adjusted odds ratio 3.41; 95 % confidence interval 2.01 to 5.78).

Conclusions: About one in five mothers reported some adverse obstetric symptoms. Obstetric problems were more common in the rural areas, whereas cesarean delivery rate was much higher in the urban areas. Further investigations are required to determine whether these cesarean sections are medically warranted or provider induced.
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http://dx.doi.org/10.1186/s12978-016-0128-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4774033PMC
March 2016

Globalization, Global Health, and Disaster.

Authors:
Rajendra Karkee

Front Public Health 2015 20;3:262. Epub 2015 Nov 20.

School of Public Health and Community Medicine, BP Koirala Institute of Health Sciences , Dharan , Nepal.

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http://dx.doi.org/10.3389/fpubh.2015.00262DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4653305PMC
December 2015

Postnatal and neonatal care after home birth: A community-based study in Nepal.

Women Birth 2016 Jun 25;29(3):e39-43. Epub 2015 Oct 25.

School of Public Health, Curtin University, WA, Australia.

Background: In Nepal, the majority of women who give birth at home do not visit a health facility for postnatal and neonatal care.

Objectives: This study investigated postnatal and neonatal care practices of women who give birth at home in a central hills district of Nepal.

Design: This study is a part of community-based prospective study in the Kaski district of Nepal. Postnatal and neonatal care practices were collected via structured questionnaires.

Setting: Kaski district of Nepal.

Participants: 92 postpartum women who gave birth at home.

Outcome Measures: Postnatal care at a health facility and neonatal care practices.

Findings: Approximately 90% (83/92) of women who gave birth at home were assisted by non-skilled birth attendants, and 67% (62/92) received no postnatal care at a health facility within a week post delivery. The main reason for not having postnatal care at a health facility was 'no perceived need' (52/62, 83.9%). With regard to neonatal care practices, 67% (62/92) used a delivery kit, 79% (73/92) washed their hands before handling their babies, 70% (64/92) bathed their babies on the second day of birth, while all dried and wrapped their babies with a cloth within half an hour of the birth. However, only 46% (42/92) reported skin-to-skin contact within one hour after birth.

Conclusions: The results suggest that there is great scope to strengthen community-based postnatal and neonatal care to screen for and identify postnatal and neonatal problems, especially at home birth.
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http://dx.doi.org/10.1016/j.wombi.2015.10.003DOI Listing
June 2016

Under-utilization of antenatal care services in Timor-Leste: results from Demographic and Health Survey 2009-2010.

BMC Pregnancy Childbirth 2015 Sep 8;15:211. Epub 2015 Sep 8.

School of Public Health, Curtin University, Perth, Australia.

Background: Timor-Leste is a young country in the Asia-Pacific region with a high maternal mortality rate of 557 per 100,000 live births. As most maternal deaths can be prevented by providing quality antenatal care (ANC) and skilled assistance during childbirth, understanding the barriers to the utilization of ANC services can enhance program implementation. This study aimed to investigate the prevalence and factors associated with the under-utilization of ANC services in Timor-Leste.

Methods: Timor-Leste Demographic and Health Survey (TDHS) 2009-2010 was a nationally representative multi-stage cross-sectional study involving 11,463 households and 9,828 childbirths. Information on last born child was recorded for 5,895 mother-child pairs. Factors influencing under-utilization of ANC were assessed using hierarchical logistic regression analysis.

Results: Only 3311 (55.2, 95% confidence interval (CI) 53.1 to 57.3%) made the recommended four ANC visits, while 2584 (44.8; 95% CI 42.7 to 46.9%) of them reported attending three or less ANC services. Significant factors positively associated with the under-utilization of ANC were low wealth status (odds ratio (OR) 2.09; 95% CI 1.68 to 2.60), no maternal education (OR 1.54; 95% CI 1.30 to 1.82) or primary maternal education (OR 1.21; 95% CI 1.04 to 1.41), no paternal education (OR 1.34; 95% CI 1.13 to 1.60), and having a big problem in permission to visit health facility (OR 1.65; 95% CI 1.39 to 1.96).

Conclusions: Despite the apparently good progress made in re-establishing the healthcare infrastructure, 45 % of mothers remained in need of a focused intervention to increase their use of ANC services. Further prenatal care program should pay attention to women with low wealth status and those and their partners who are uneducated. Moreover, women should be encouraged to make decision on their own health.
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http://dx.doi.org/10.1186/s12884-015-0646-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4563848PMC
September 2015

Postpartum Breastfeeding Promotion and Duration of Exclusive Breastfeeding in Western Nepal.

Birth 2015 Dec 26;42(4):329-36. Epub 2015 Aug 26.

School of Public Health, Curtin University, Perth, Australia.

Background: Encouragement and skills provided to mothers during the postpartum period have been found to be successful in increasing exclusive breastfeeding rates. However, evidence from developing countries is limited. This study aimed to ascertain whether education and skill support provided by health workers during the postpartum period were associated with increased duration of exclusive breastfeeding in Western Nepal.

Methods: A community-based prospective cohort study was conducted between January and October 2014, in the Rupandehi district of Nepal. Information on breastfeeding promotion provided by health workers after birth was collected from 649 mothers. The association between breastfeeding promotion and exclusive breastfeeding was investigated using multivariable Cox regression analysis.

Results: Of the 649 mothers, 35 percent received all eight types of breastfeeding promotion advice, and 60 percent received six or more such types of advice. Breastfeeding promotion, such as "breastfeeding on demand" (hazard ratio [HR] 0.74 [95% CI 0.59-0.92]) and "not to provide pacifier or teats" (HR 0.82 [95% CI 0.68-0.97]), were significantly associated with a lower risk of exclusive breastfeeding cessation. The dose-response relationship was also significant for the number of advices received (HR 0.94 [95% CI 0.90-0.97]).

Conclusions: This study provides evidence that breastfeeding education and support immediately after childbirth could increase the duration of breastfeeding. The results suggest further attention to breastfeeding promotion in all maternity hospitals and birthing centers through skilled birth attendants.
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http://dx.doi.org/10.1111/birt.12184DOI Listing
December 2015

Factors associated with Early Initiation of Breastfeeding in Western Nepal.

Int J Environ Res Public Health 2015 Aug 14;12(8):9562-74. Epub 2015 Aug 14.

School of Public Health, Curtin University, Perth 6102, Australia.

The initiation of breastfeeding within one hour of birth has numerous nutritional and immunological benefits and has been found to reduce neonatal mortality. This community-based prospective cohort study aimed to report the rate of, and factors associated with, early initiation of breastfeeding in Western Nepal. The rate of early initiation of breastfeeding was reported, and associations between early initiation and independent variables were tested by Chi-square test, followed by multiple logistic regression. Of the 735 mother-infant pairs, a total of 310 (42.2%) reported early initiation. Mothers who were assisted by traditional attendants during childbirth, delivered by caesarean section, from ethnically disadvantaged families and had delivered low birth weight infants, were less likely to initiate breastfeeding early whereas the mothers who were from the poorest families and did not introduce prelacteal feeds to their infants were more likely to initiate breastfeeding within the first hour. Skills-training to support breastfeeding as part of the training of skilled birth attendants and other health workers is likely to promote recommended infant feeding practices.
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http://dx.doi.org/10.3390/ijerph120809562DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4555298PMC
August 2015

Prevalence and factors associated with prelacteal feeding in Western Nepal.

Women Birth 2016 Feb 4;29(1):12-7. Epub 2015 Aug 4.

School of Public Health, Curtin University, Perth, Australia.

Background: Newborn infants are often given prelacteal feeds in Nepal despite government policies encouraging exclusive breastfeeding for the first six months of life.

Aim: This study investigated the prevalence, reasons, types and factors associated with prelacteal feeding in the south-western region of Nepal.

Methods: Information on prelacteal feeding was obtained from 735 recently delivered women who were recruited for a prospective community-based cohort study conducted during 2014 in the Rupandehi district of Nepal. Factors associated with prelacteal feeding were assessed using logistic regression analysis.

Findings: A total of 225 (30.6%) mothers reported giving prelacteal feeds to their infants. The most popular prelacteal food was formula milk (41.7%), followed by cow or buffalo milk (26.6%), and sugar/glucose water (12.4%). Caesarean delivery (17.3%), cultural preference (16.4%) and being tired after childbirth (10.6%) were the most commonly cited reasons. Almost half (48%) of the mothers were advised by their mother/mother-in-law on prelacteal feeding method. Higher parity (adjusted odds ratio (OR) 2.05; 95% confidence interval (CI) 1.18-3.54), low birthweight (OR 1.97; 95% CI 1.23-3.16), caesarean delivery (OR 3.70; 95% CI 2.37-5.80) and wealthy status (OR 2.49; 95% CI 1.52-4.06) were associated with prelacteal feeding.

Conclusion: Nearly one-third of the infants in this study were given prelacteal feeds. Future breastfeeding promotion programmes should focus on the mothers with low birthweight infants, of high parity, from a wealthy family and those who had caesarean delivery.
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http://dx.doi.org/10.1016/j.wombi.2015.07.006DOI Listing
February 2016

Defining and Developing a Global Public Health Course for Public Health Graduates.

Front Public Health 2015 1;3:166. Epub 2015 Jul 1.

School of Public Health, Curtin University , Perth, WA , Australia.

Global public health is increasingly being seen as a speciality field within the university education of public health. However, the exact meaning of global public health is still unclear, resulting in varied curricula and teaching units among universities. The contextual differences between high- and low- and middle-income countries, and the process of globalization need to be taken into account while developing any global public health course. Global public health and public health are not separable and global public health often appears as an extension of public health in the era of globalization and interdependence. Though global public health is readily understood as health of global population, it is mainly practiced as health problems and their solutions set within low- and middle-income countries. Additional specialist competencies relevant to the context of low- and middle-income countries are needed to work in this field. Although there can be a long list of competencies relevant to this broad topic, available literature suggests that knowledge and skills related with ethics and vulnerable groups/issues; globalization and its impact on health; disease burden; culture, society, and politics; and management are important.
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http://dx.doi.org/10.3389/fpubh.2015.00166DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4486750PMC
July 2015

Factors associated with early initiation of breastfeeding among Nepalese mothers: further analysis of Nepal Demographic and Health Survey, 2011.

Int Breastfeed J 2014 5;9(1):21. Epub 2014 Dec 5.

Centre for International Health, Curtin University, Perth, Australia.

Background: Timely initiation of breastfeeding has been reported to reduce neonatal mortality by 19.1%. The World Health Organisation recommends early initiation of breastfeeding i.e. breastfeeding a newborn within the first hour of life. Knowledge on the rate and the determinants of early initiation of breastfeeding may help health program managers to design and implement effective breastfeeding promotion programs. The aim of this study was to determine the rate and the determinants of early initiation of breastfeeding in Nepal.

Methods: This study used the data from Nepal Demographic and Health Survey (NDHS) 2011 which is a nationally representative sample study. Chi square test and multiple logistic regression analysis were used to examine the factors associated with early initiation of breastfeeding (within one hour of birth).

Results: Of 4079 mothers, 66.4% initiated breastfeeding within one hour of delivery. Mothers with higher education (Odds Ratio (OR) 2.56; 95% CI : 1.26, 5.21), mothers of disadvantaged Janjati ethnicity (OR 1.43; 95% CI : 1.04, 1.94), mothers who were involved in agriculture occupation (OR 1.51; 95% CI : 1.16, 1.97), mothers who delivered in a health facility (OR 1.67; 95% CI : 1.25, 2.23), whose children were large at birth (OR 1.46; 95% CI : 1.07, 1.99) were more likely to initiate breastfeeding within the first hour of child birth.

Conclusions: Results suggest that two thirds of children in Nepal were breastfed within the first hour after birth. Although there was a higher prevalence of early initiation of breastfeeding among mothers who delivered in health facilities compared to mothers who delivered at home, universal practice of early initiation of breastfeeding should be a routine practice. The findings suggest the need of breastfeeding promotion programs among the mothers who are less educated, and not working. Such breastfeeding promotion programmes could be implemented via Nepal's extensive network of community-based workers.
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http://dx.doi.org/10.1186/s13006-014-0021-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4260185PMC
December 2014

The role of obstetric knowledge in utilization of delivery service in Nepal.

Health Educ Res 2014 Dec 1;29(6):1041-8. Epub 2014 Oct 1.

School of Public Health and Community Medicine, BP Koirala Institute of Health Sciences, Dharan, Stichting Sarangkot, Kaski, Sanjeevani College of Medical Sciences, Butwal, Rupandehi, Nepal and School of Public Health, Curtin University, Perth, WA, Australia.

Birth Preparedness and Complication Readiness (BP/CR) program has been promoted in Nepal to equip pregnant women with obstetric knowledge so as to motivate them to seek professional care. Using a prospective design of 701 pregnant women of more than 5 months gestation in a central hills district of Nepal, we evaluated if having obstetric knowledge could make a difference in maternal delivery behaviour. The results suggested that BP/CR program was effective in raising women's obstetric knowledge, which was significantly associated with facility delivery according to logistic regression analysis. In particular, women who acknowledged that unexpected problems could occur during pregnancy and childbirth were more likely (odds ratio [OR] 5.83, 95% confidence interval [CI] 2.95-11.52) to deliver at a health facility than others unaware of the possible consequences. Similarly, women who knew any antepartum danger sign (OR 2.16, 95% CI: 1.17-3.98), any intrapartum danger sign (OR 3.80, 95% CI: 2.07-6.96) and any postpartum danger sign (OR 3.47 95% CI: 1.93-6.25), tended to deliver at a health facility. Convincing and counselling the pregnant women of the health consequences of pregnancy and childbirth would increase their utilization of delivery service.
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http://dx.doi.org/10.1093/her/cyu059DOI Listing
December 2014

A community-based prospective cohort study of exclusive breastfeeding in central Nepal.

BMC Public Health 2014 Sep 8;14:927. Epub 2014 Sep 8.

School of Public Health and Community Medicine, BP Koirala Institute of Health Sciences, Dharan, Nepal.

Background: Existing information on breastfeeding in low income countries such as Nepal has been largely derived from cross-sectional demographic health surveys. This study investigated exclusive breastfeeding rates, and compared the duration of exclusive breastfeeding between rural and urban mothers in central Nepal using an alternate cohort methodology.

Methods: A community-based prospective cohort study was conducted among 639 recently delivered mothers representative of the Kaski district of Nepal. Breastfeeding information was obtained at birth (n = 639), 4 weeks (n = 639), 12 weeks (n = 615; 96.2%) and 22 weeks (n = 515; 80.6%) through repeated interviews using validated questionnaires. Risk of cessation of exclusive breastfeeding was assessed by Cox regression analysis.

Results: The great majority of women received breastfeeding information (74%) and were encouraged to breastfeed by health personnel or family members (81%). Although nearly all mothers (98%) breastfed up to six months, the reported exclusive breastfeeding rate declined rapidly from 90.9% at birth to 29.7% at 22 weeks. Urban women experienced significantly shorter (p = 0.02) exclusive breastfeeding duration (mean 104.5, 95% CI 95.8 to 113.1 days) and were more likely to cease exclusive breastfeeding (hazard ratio (HR) 1.28, 95% CI 1.03 to 1.60) than their rural counterparts (mean 144.7, 95% CI 132.3 to 157.1 days). Breastfeeding problem (HR 2.07, 95% CI 1.66 to 2.57) and caesarean delivery (HR 1.88, 95% CI 1.36 to 2.62) were also significantly associated with exclusive breastfeeding cessation.

Conclusions: Despite the almost universal practice of breastfeeding, the reported exclusive breastfeeding rates declined substantially over time. Exclusive breastfeeding up to six months was more common in rural than urban areas of central Nepal. Urban mothers also exclusively breastfed shorter than rural mothers.
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http://dx.doi.org/10.1186/1471-2458-14-927DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4161870PMC
September 2014

Infant feeding information, attitudes and practices: a longitudinal survey in central Nepal.

Int Breastfeed J 2014 28;9:14. Epub 2014 Aug 28.

School of Public Health, Curtin University, Perth, WA, Australia.

Background: Infant feeding is governed by environmental as well as cultural factors. Breastfeeding knowledge and attitudes are known to be associated with breastfeeding duration. This study investigated breastfeeding information, attitudes and supplementary feeding in the central hills district of Nepal.

Methods: A community-based prospective cohort study of 701 pregnant women was conducted. Information on breastfeeding attitudes, feeding practices and supplementary feeding was sought from the cohort at 4 weeks, 12 weeks and 22 weeks postpartum through repeated interviews using validated questionnaires.

Results: Average duration of intended breastfeeding was 28 months (SD 7.9) and average target time to introduce solid foods was 6.1 months (SD 1.2). About 80% of women reported their husband, mother/mother-in-law preferred breastfeeding. Eleven percent of the cohort said that breastfeeding was not enjoyable. At 12 weeks and 22 weeks after birth, about a quarter (24.8%) and half (52.8%) of the infants were introduced cow/buffalo milk, respectively, while only 6.3% and 13.4% of them were given infant formula. Overall, any breastfeeding rate remained high at over 98% throughout the follow up period.

Conclusions: Breastfeeding attitudes were encouraging in this population. Breastfeeding was almost universal. Use of infant formula was quite low, whereas cow or buffalo milk appeared to be popular supplementary foods.
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http://dx.doi.org/10.1186/1746-4358-9-14DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4149806PMC
September 2014

Public health education in South Asia: a basis for structuring a master degree course.

Authors:
Rajendra Karkee

Front Public Health 2014 21;2:88. Epub 2014 Jul 21.

School of Public Health and Community Medicine, B. P. Koirala Institute of Health Sciences , Dharan , Nepal.

Countries in South Asian Association for Regional Cooperation (SAARC) lack enough public health workforces to address their poor public health situation. Recently, there have been efforts to develop capacity building in public health in these countries by producing competent public health workforce through public health institutes and schools. Considering the wide nature of public health, the public health education and curricula should be linked with skills, knowledge, and competencies needed for public health practice and professionalism. The 3 domains of public health practice and the 10 essential public health services provide an operational framework to explore this link between public health practice and public health education. This framework incorporates five core areas of public health education. A master degree course in public health can be structured by incorporating these core areas as basic and reinforcing one of these areas as an elective followed by a dissertation work.
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http://dx.doi.org/10.3389/fpubh.2014.00088DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4104799PMC
August 2014

Factors associated with non-utilisation of health service for childbirth in Timor-Leste: evidence from the 2009-2010 Demographic and Health Survey.

BMC Int Health Hum Rights 2014 May 5;14:14. Epub 2014 May 5.

Sanjeevani College of Medical Sciences, Butwal, Rupandehi, Nepal.

Background: Timor-Leste is a young developing country in Asia. Most of its infrastructure was destroyed after a long armed conflict for independence. Despite recent expansion of health facilities and investment in healthcare, maternal mortality remains high with most mothers still giving birth at home. This study investigated factors affecting the non-utilisation of health service for childbirth in the aftermath of the independence conflict.

Methods: The Timor-Leste Demographic and Health Survey 2009-2010 was the latest two-stage national survey, which used validated questionnaires to obtain information from 26 clusters derived from 13 districts of the country. Factors influencing non-utilisation of health facility for childbirth were investigated using univariate and multivariable logistic regression analyses, accounting for the cluster sampling and sample weight of the survey.

Results: Of the total 5986 participants included in the study, 4472 (74.8%) did not deliver their last child at a health facility. Lack of education for the mother (adjusted odds ratio (OR): 2.04; 95% confidence interval (CI) 1.56 to 2.66) and her partner (OR: 1.45; 95% CI 1.14 to 1.84), low household wealth status (OR: 5.20; 95% CI 3.93 to 6.90), and rural residence (OR: 2.83; 95% CI 2.22 to 3.66), were associated with increased likelihood of non-utilisation of health facility for childbirth. Working mothers (OR: 1.55; 95% CI 1.32 to 1.81), who had high parity (OR: 1.78; 95% CI 1.36 to 2.32) and did not attend antenatal care service (OR: 4.68; 95% CI 2.65 to 8.28) were also vulnerable for not delivering at a health facility. Conversely, the prevalence of non-utilisation of health facility for childbirth reduced with increasing number of service components received during antenatal care visits (OR: 0.72; 95% CI 0.64 to 0.80).

Conclusions: Only a quarter of Timorese women delivered at a health facility. In order to reduce maternal mortality, future interventions should target disadvantaged mothers from poor families, those residing in rural areas, have higher parity but no education, and who seldom attend antenatal care service, by improving their utilisation of health facility for childbirth.
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http://dx.doi.org/10.1186/1472-698X-14-14DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4026833PMC
May 2014

Prelacteal feeding of newborns in postconflict Timor-Leste.

J Pediatr Gastroenterol Nutr 2014 Aug;59(2):162-6

*School of Public Health, Curtin University, Perth, Australia †National Hospital Guido Valadares, Ministry of Health, Dili, Timor-Leste ‡School of Public Health and Community Medicine, BP Koirala Institute of Health Sciences, Dharan, Nepal.

Objectives: The aim of the present study was to investigate the prevalence of prelacteal feeding and its associated factors in Timor-Leste using updated data from the national survey.

Methods: Complex sample analysis was undertaken to account for the 2-stage cluster design of the Demographic and Health Survey 2009-2010. Backward stepwise logistic regression was conducted to ascertain factors associated with the prevalence of prelacteal feeding.

Results: A total of 4821 mother-infant pairs were included in the analysis. The prevalence of prelacteal feeding was 12.3% (95% confidence interval [CI] 11.1-13.5). The most popular prelacteal food was plain water (50.7%), followed by glucose/sugar water (32.5%) and milk other than breast milk (22.7%). Older mothers (35-49 years), mothers with upper socioeconomic status, those who perceived their newborns as small size, and those residing in urban areas were approximately 1.5 times more likely to give prelacteal feeds, whereas women who followed religions other than Roman Catholic had twice the risk (adjusted odds ratio 1.98; 95% CI 1.16-3.41).

Conclusions: Antenatal and postnatal counselling sessions that promote exclusive breast-feeding and discourage prelacteal feeding are needed that specifically target these vulnerable subgroups of Timorese mothers.
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http://dx.doi.org/10.1097/MPG.0000000000000429DOI Listing
August 2014
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