<figure><img width="1400" height="933" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022111412114/6372218c9c7e80680e0c02c1jpeg.jpg" alt=""/><figcaption>Photo: GOPEN RAI/NEPALI TIMES ARCHIVE</figcaption></figure>A new study in Nepal has found that more female babies die after the third week of birth than male ones. Even though more male babies die in the first week after birth, the survey points to how gender discrimination may be disproportionately claiming the lives of girl children.The findings have larger implications for Nepal’s target to reduce the Neonatal Mortality Rate (NMR) to 12 deaths per 1,000 live births by 2030 as per the Sustainable Development Goals (SDGs). At present, the figure stands at 21. Neonatal mortality is the death of a child between 0- 28 days of birth. It can be categorised into early (0-7 days) and late neonatal death (7-28 days). NMR is an important indicator of maternal and newborn health, which shows a country’s quality of life. Generally, male children are at an approximately 20% greater risk of succumbing to neonatal mortality than girls. Several factors associated with higher neonatal mortality among male children include intrauterine growth restriction, respiratory distress syndrome, prematurity and birth asphyxia. Animal model studies have shown that testosterone suppresses the immune system, while oestradiol and progesterone in females improve immune responses which means they are better able to fight infections. Data from high-income countries reveal that it is true not only during the neonatal period, but later on in life as well. In low and middle-income countries males are at a higher risk of mortality in the early neonatal period but more females die in the late neonatal stage. But the specific age (days) where this reversal takes place was not previously known.Which is why <a href="https://www.researchgate.net/publication/360724893_Does_higher_eArticle_Does_higher_early_neonatal_mortality_in_boys_reverse_over_the_neonatal_period_A_pooled_analysis_from_three_trials_of_Nepal#fullTextFileContent" target="_blank" rel="noopener noreferrer">we conducted a study</a> to examine sex differentials in neonatal mortality by detailed ages (0-1, 1-3, 3-7, 7-14,14-21 and 21-28 days). This is the first study to look at the sex differentials by such granular ages.We looked into data from three sequential, community-based randomised controlled trials (RCTs) in Sarlahi district of the southern plains of Nepal. The studies provide pregnancy cohorts from 1999 through 2017.Neonatal mortality was 41.9 (44.2 vs 39.7 in boys and girls), 30 (30.5 vs 29.6 in boys and girls) and 31.4 (33.4 vs 29.4 in boys and girls) in 1999, 2002 and 2010 studies respectively. A common finding in all three studies was that male mortality was higher in the early neonatal period (0-7days), but there was a reversal after the third week of life (21-28 days), where female mortality was higher. <figure><img width="1210" height="880" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022111412118/637221909c7e80680e0c02c2jpeg.jpg" alt=""><figcaption>Graphs: SEEMA SUBEDI</figcaption></figure><img width="1210" height="880" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022111412118/637221949c7e80680e0c02c3jpeg.jpg" alt=""><img width="1210" height="880" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022111412118/637221969c7e80680e0c02c4jpeg.jpg" alt="">Data from the three studies were combined and analysed with average neonatal mortality coming to 31.6 (33.0 vs 30.2 in boys and girls). When we break this down to sex differentials in mortality by granular ages, male mortality was 1.17 times higher in the early neonatal period. However, this natural pattern was quickly reversed after the third week when female mortality was 2.43 times higher.This begs a question: why this reversal?Our paper does not examine the reasons, but studies in South Asia have found higher care-seeking behaviour for male neonates than females, particularly in households with older female siblings. Moreover, for male babies, care-seeking was more frequent with better-qualified care providers and higher expenditure compared to that of girls. Studies have also shown that households with female children were more likely to report discrimination because family members perceived that care for illness was not so important leading to reduced care-seeking.Nepal has been categorised to have a high level of son preference ever since the 1980s in World Fertility Surveys. Not much has changed since then as proven by a 2012 survey where 90% of 1,000 Nepali men aged 18-49 years said that a man with only daughters was unfortunate, and not having a son reflects a lack of moral virtue. Nearly half of them said that a woman’s important roles were limited to taking care of her home and cooking for her family. Nepal’s patrilineal and patrilocal social structure combined with socio-economic and religious values lead to son preference and gender discrimination. Traditionally, sons have been given certain cultural and economic roles such as the lighting of the funeral pyre, continuing the family lineage and providing old-age economic security for their parents. This places them above girls who are considered an economic liability because they have to be married off and with a dowry. And upon marriage, they become part of the economy of the husband’s family. Given the social norms, the baby survival differential may be explained by poorer nutrition, care and rest provided to mothers giving birth to daughters, son preference being the root cause of discrimination in the family. It could also point to specific parental behaviours that take place starting at that age (21-28 days of a child’s life).  <img width="1210" height="880" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022111412118/637221999c7e80680e0c02c5jpeg.jpg" alt="">However, the 3-week threshold could also just be an indication that the gender discrimination starts from birth or even earlier, but takes at least three weeks for the biological and natural survival advantage of females to be overcome by the social advantage of males.Neonatal mortality in Nepal has continued to decrease from 39 to 21 per 1,000 live births, with male neonatal mortality decreasing from 52 to 24 (reduction of 28 per 1,000) and female neonatal mortality from 43 to 17 (reduction of 26 per 1,000) from 2001 to 2016. Given that boys have a biological disadvantage in neonatal survival, one would have expected female neonatal mortality to decrease significantly over time. A reduction in female neonate mortality would also mean an overall decrease in neonatal mortality. But as it is, it is unlikely Nepal will meet its target of reducing NMR to 12 by 2030. Gender discrimination not only affects the quality of life of girls and women, but also reduces their survival in the neonatal period. A cross-national study from 138 countries also showed that higher the gender inequality index, higher the neonatal mortality of a country. Read more: <a href="http://archive.nepalitimes.com/regular-columns/GUEST-COLUMN/Saving-one-mother-at-a-time,816">Saving one mother at a time</a>, Bikash GauchanAddressing gender discrimination by removing cultural and social barriers at the household level may help reduce overall neonatal mortality. Interventions to strengthen gender equality, such as counselling women and their families during antenatal and postnatal care visits may significantly improve female and male neonatal survival.Since the reversal takes place during the fourth week, specific interventions should be targeted in the first three weeks of a child’s life.Seema Subedi is Faculty Associate in the Global Disease Epidemiology and Control Division of the International Health Department at the Johns Hopkins Bloomberg School of Public Health in Baltimore, USA.

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Fatal discrimination

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022110914114/636ba5fc9c7e80680e0736f8jpeg.jpg" alt="" width="1500" height="1000"/><figcaption>Photo: RSS</figcaption></figure>A report published online in the journal <a href="https://www.thelancet.com/action/showPdf?pii=S2214-109X%2820%2930345-4" data-saferedirecturl="https://www.google.com/url?q=https://www.thelancet.com/action/showPdf?pii%3DS2214-109X%252820%252930345-4&amp;source=gmail&amp;ust=1597502712571000&amp;usg=AFQjCNHILFhzVJvsa3-jDtOse6F5jqCotw">The Lancet Global Health</a> this week revealed that the COVID-19 pandemic has caused 50% fewer women in Nepal than usual to give birth in hospitals, resulting in higher risks for premature births, stillborn deliveries and newborn deaths.The study, conducted in nine hospitals across Nepal found that the stillbirth rate at hospitals and birthing centres increased from 14 per 1,000 before the lockdown to 21, and the neonatal mortality increased from 13 per 1,000 livebirths to 40.‘An urgent need exists to protect access to high quality intrapartum care and prevent excess deaths for the most vulnerable health system users during this pandemic period,’ the report noted.While the study focused on the indirect impacts of the pandemic on maternal and neonatal health service delivery, and did not attempt to calculate deaths resulting from these impacts, it warned: ‘During the COVID-19 pandemic, women and their babies (both in utero and neonates) are susceptible and at risk due to gaps in care that can result in adverse birth outcomes, including mortality.’It continued: ‘The decrease in the number of institutional births and increase in adverse outcomes are especially concerning because of Nepal’s fragile health system, and raisequestions on policies regarding strict lockdowns in low-income and middle-income countries.’In fact, <a href="https://www.nepalitimes.com/banner/children-are-collateral-damage-in-nepal-lockdown/" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/banner/children-are-collateral-damage-in-nepal-lockdown/&amp;source=gmail&amp;ust=1597502712571000&amp;usg=AFQjCNF8MuMWip3DU9TRCsEF_50a5L1Atg">Nepali Times had reported</a> earlier this year that ‘many more children have died during the four months of lockdown compared to the same period last year because of lack of access to health care due to the restriction on mobility, interrupted vaccination campaigns and the lack of medicines.’‘Initial government figures also show that a total of 204 children under 5 have died across the country during the lockdown between 14 March-14 June. This number was at a much lower 151 during the same period last year,’ our report said.According to Lubna Baqi, Nepal Country Representative for the UN Population Fund (UNFPA): “The finding of (this week’s) study are deeply troubling. A drop in institutional deliveries by 52.4% has significant implications on health outcome as noted in the study. A further drop in institutional deliveries will have a devasting impact on maternal and newborn health.”An online rapid assessment by UNFPA in April found a similar decline, about one-half, in deliveries in health institutions. In June, Ministry of Health Spokesperson Mahendra Shrestha said fewer than 45% of women were giving birth in facilities, down from 75% before the Coronavirus pandemic.The Lancet study, based on monitoring in nine hospitals in Nepal, found decreases in:-       Institutional births (by roughly 50%)-       Foetal heart rate monitoring during labour-       Breastfeeding within one hour of birth-       Women being accompanied during delivery.The authors speculate that ‘the increase in preterm birth could also be associated with the distress of COVID-19-related social restrictions, considering psychosocial stress during pregnancy .’They add: ‘The increased proportion of admitted women having complications during admission, including preterm birth, during the COVID-19 lockdown period, might suggest that women at high risk of complications are disproportionately attending health facilities or that the number of complicated cases has increased due to delays and other challenges of the lockdown.’Those challenges are unfortunately already familiar in Nepal: lack of transportation to health facilities, a shortage of personal protective equipment (PPE), lack of gloves and other equipment for managing childbirth, and poor readiness of health facilities, etc.The Lancet study did report witnessing some improved practices, such as more skin-to-skin contact between mothers and newborns and better hand-washing. It suggests a ‘need to continue communication with policy makers and programme coordinators to address such inequalities and coverage gaps so that additional deaths can be averted’.In an interview earlier this year Baqi noted, “It’s good to have the ministry of health at the federal level saying, ‘Of course essential services must continue’ but there’s a big gap in implementation.”On Friday she added via email: ‘While current attention is on preventing and treating COVID-19 cases, it is likely that maternal and newborn mortality has increased across the country due to poor utilisation of services on the one hand and lack of preparedness on the other hand.’Baqi also pointed to shortages of trained personnel — including skilled birth attendants — essential life-saving drugs and PPEs. “The above concerns have received inadequate attention, among competing priorities, and limited financial resources have been mobilised to bridge the gaps in reproductive, maternal, child and adolescent health,” she said.The Lancet Global Health paper concludes: ‘Pandemic lockdowns threaten lives and jeopardise progress that has been made in the past two decades in Nepal, potentially derailing on-track efforts to achieve the Sustainable Development Goals by 2030, especially for maternal and neonatal survival.’

Infant deaths up during Nepal lockdown

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109141136/636badaf9c7e80680e077fabjpeg.jpg" alt="" width="1400" height="933"/><figcaption>Photo: GOPEN RAI</figcaption></figure>On Friday, it will be four months since Nepal closed the country down to prevent the spread of  SARS-CoV-2, the virus strain that causes COVID-19. Of the 40 who have died of the infection in Nepal, two are children below 5.But many more children have died during the four months of lockdown compared to the same period last year because of lack of access to health care due to the restriction on mobility, interrupted vaccination campaigns and the lack of medicines.However, the coronavirus grabs all the headlines. Mortality due to non-COVID-19 causes does not make the news – even though it is clear that a lockdown enforced to control one disease has caused far more deaths from other prevalent diseases, and threatens to undermine Nepal’s progress in infant and child survival over the past four decades.“The COVID-19 crisis and lockdown have pushed many families into poverty, many have lost their sources of income, l<a href="https://www.nepalitimes.com/latest/eu-unicef-support-child-nutrition-during-lockdown/" target="_blank" rel="noopener noreferrer">eading to malnourishment among children</a>,” says Jhalak Gautam of the Child Health Division at the Health Ministry. “Increased malnutrition means children are more susceptible not only to COVID-19 but to many other infectious diseases such as measles and diphtheria.”Under-5 child mortality rate in Nepal had declined substantially from 271 deaths per 1,000 live births in 1969 to 32 in 2018. Government figures show that since 17 July 2018-16 July 2019, a total of 1,357 children under 5 died of various infectious diseases all over the country. Preliminary figures for the same period 2019-2020 is 1,263 – even though only 78% of the data has been collected.Initial government figures also show that a total of 204 children under 5 have died across the country during the lockdown between 14 March-14 June. This number was at a much lower 151 during the same period last year.This data clearly show that the total child death numbers collected by Female Health Care Volunteers is higher this year — meaning they died at home. The number of those who have died at hospital in the same three months this year is lower than last year probably because parents are not taking children to hospital when they are sick during the lockdown.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109141140/636badb39c7e80680e077facjpeg.jpg" alt="" width="1714" height="1210"><figcaption> </figcaption></figure>An expert at the Health Information Management System says when all the data for this year comes in, it is bound to be much higher than last year. This means the lockdown has pushed Nepal back in meeting its health targets under the United Nations’ SDGs (Sustainable Development Goals).Under the SDG target, Nepal is supposed to bring child mortality down further to 25 deaths per 1,000 live births by 2030. Persistent childhood malnutrition is a major reason for infant and child mortality remaining high despite dramatic progress in the 1990s. <a href="https://www.nepalitimes.com/banner/nearly-half-of-nepali-children-still-malnourished/" target="_blank" rel="noopener noreferrer">Figures for stunting, wasting and anaemia in Nepal have plateaued in the last decade</a>  Now, the lockdown has added to the challenge.Says Elke Wisch, UNICEF Representative to Nepal: “Progress made on children’s nutrition in the last decade is at risk of being reversed as rising numbers of children are facing malnutrition due to loss of household income and resulting food insecurity. The social and economic loss for Nepal resulting from the deterioration in children’s nutrition status will be felt long after the COVID 19 crisis is over.”The lockdown has also disrupted <a href="https://www.nepalitimes.com/banner/a-shot-in-the-arm-for-vaccines-in-nepal/" target="_blank" rel="noopener noreferrer">vaccination campaigns</a> across the country, leading to <a href="https://www.nepalitimes.com/here-now/meanwhile-a-measles-outbreak-in-nepal/" target="_blank" rel="noopener noreferrer">measles outbreaks in Dhading and Gorkha</a> in April. Although regular immunisation services have now been restored in health facilities in all 77 districts, parents have been unable to take their children for shots because of restrictions on transportation and also because of the fear of COVID-19 transmission in health posts.In fact, the WHO and UNICEF earlier this week stated that preliminary data for the first four months of 2020 points to a <a href="https://www.who.int/news-room/detail/15-07-2020-who-and-unicef-warn-of-a-decline-in-vaccinations-during-covid-19" target="_blank" rel="noopener noreferrer">substantial drop in the number of children completing three doses of the vaccine</a> against diphtheria, tetanus and pertussis (DTP3), first time in 28 years. Moreover, at least 30 measles vaccination campaigns were or are at risk of being cancelled, which could result in further outbreaks in 2020 and beyond.“Vaccines are one of the most powerful tools in the history of public health, and more children are now being immunised than ever before,” said Tedros Adhanom Ghebreyesus, WHO Director-General. “But the pandemic has put those gains at risk. The avoidable suffering and death caused by children missing out on routine immunizations could be far greater than COVID-19 itself.”With schools closed for the past four months, children in many schools are also not getting their lunches. Domestic violence has also seen a spike during the lockdown, with many of the victims children. There is also evidence of a <a href="https://www.nepalitimes.com/latest/child-marriages-up-during-nepal-lockdown/" target="_blank" rel="noopener noreferrer">rise in child marriage</a>  anxiety, stress and <a href="https://www.nepalitimes.com/here-now/post-pandemic-mental-health-epidemic/" target="_blank" rel="noopener noreferrer">mental disorder</a>Nepal appears to be on track to proving correct the grim prediction in May by the Johns Hopkins Bloomberg School of Public Health that 1.2 million children worldwide could die from pre-existing diseases like malaria, pneumonia or diarrhoea in the next six months due to the disruption to health services and food supplies due to the lockdown. That makes <a href="https://www.nepalitimes.com/latest/pre-existing-diseases-may-kill-more-children/" target="_blank" rel="noopener noreferrer">6,000 fatalities a day</a> – a whopping 45% rise in child mortality.“Under a worst-case scenario, the global number of children dying before their fifth birthdays could increase for the first time in decades,” UNICEF Executive Director Henrietta Fore warned. “We must not let mothers and children become collateral damage in the fight against the virus. And we must not let decades of progress on reducing preventable child and maternal deaths be lost.”<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109141140/636badb69c7e80680e077fadjpeg.jpg" alt="" width="3600" height="2400"><figcaption> </figcaption></figure>Another aspect of the pandemic that Nepal has to be careful about is that while worldwide data show that children are relatively safe from contracting SARC CoV-2 which has mainly affected people above 70 years, in Nepal children also seem vulnerable.Health Ministry data show that the rate of infection among children below 5 is 2.2% and increasing – much higher than the global average. The infection rate among young children was at just 1% a month and a half ago.Many of the infected children belong to families who returned from India in the past three months, but children have also been infected by people who flouted lockdown rules and safety measures. This is why Far-west Province has the highest coronavirus infection rate among children at 5%.Nepal has also seen a <a href="https://www.nepalitimes.com/latest/why-are-younger-people-in-poor-countries-dying-of-covid-19/" target="_blank" rel="noopener noreferrer">disproportionate number of COVID-19 infections and mortality among a younger population</a>  Experts say this is mainly due to young returnee migrant workers from India, Malaysia and the Gulf, who make for the majority of the coronavirus cases in the country. Moreover, testing across the country so far has focused on returnees.“Unlike elsewhere, in Nepal people with co-morbidity have a higher risk of dying regardless of the age group, and this is worrying,” says epidemiologist Sher Bahadur Pun of the Health Ministry. “But we must widen our testing to come to a concrete conclusion about this. So, <a href="https://www.nepalitimes.com/opinion/prevention-while-searching-for-a-cure/" target="_blank" rel="noopener noreferrer">until we have a vaccine</a> we must wear masks, maintain physical distance and follow hand hygiene. This includes children.”

child-mortality

Fatal discrimination

Infant deaths up during Nepal lockdown

Children are collateral damage in Nepal lockdown