Over the last two decades, Nepal has made notable progress in maternal and neonatal healthcare. The<a href="https://mohp.gov.np/uploads/Resources/Final%20Report-26%20March-%202023-UPDATED.pdf"> maternal mortality ratio (MMR</a>) has declined from 536 per 100,000 live births in 1996 to 151 by 2021.
Driving this process were the country’s <a href="https://mohp.gov.np/program/safe-motherhood-programme/en">Safe Motherhood policy</a>, an increase in skilled healthcare providers, free delivery services for expectant mothers, incentive schemes for antenatal care, as well as postnatal visits.
Other measures, such as birth preparedness packages along with systematic planning for managing potential complications during childbirth, amplified these achievements.&nbsp;
There has been a remarkable rise in institutional deliveries, an increase in antenatal visits, and an impressive 70% of women receiving postpartum care from healthcare providers within the first two days after giving birth.
Quality improvement initiatives such as the Maternal and Perinatal Death Review, minimum health facility assessment standards, routine clinical monitoring, and supportive onsite supervision visits, have been outlined in policy documents and guidelines to elevate the overall quality of care.&nbsp;
However, it is when analysing province-wise MMR. that we still see significant disparities. Maternal deaths are still high in Lumbini Province (207 per 100,000 live births) and Karnali (172). The MMR in Bagmati Province (98) correlates with better figures for higher education, awareness and access to health service and providers.
In contrast, 83% of women in Karnali face challenges in seeking medical care, primarily due to financial constraints and long distance to healthcare facilities.
Half of the maternal deaths in Nepal are of mothers within the age groups of 15-34. Despite the legal marriage age being 20, child marriage is still widespread and contributes to the highest number of pregnancy-related deaths.&nbsp;
Read Also: <a href="https://nepalitimes.com/news/remove-barriers-to-life-saving-drug-to-prevent-maternal-deaths">Remove barriers to life-saving drug to prevent maternal deaths</a>, Marty Logan
The median age of marriage in Nepal is 18.3 years, with the lowest median age in Madhes province at 16.6 years and the highest in Bagmati province at 19.9 years. The Muslim community reports the lowest at 16.5 years, while the Janajati and Brahmin/Chettri communities have generally higher median ages for marriage.
In Madhes and Sudur Paschim Provinces early marriages among girls under 15 contribute to heightened adolescent mortality, mainly due to difficulties accessing timely health facilities. Disparities persist among ethnic groups, particularly among doubly marginalised Madhesi Muslims, who face high mortality rates due to early marriages.
Health facility deliveries have improved from 10% in 2001 to 79% in 2021. But again, progress is uneven and these disparities need to be overcome to<a href="https://nepalitimes.com/editorial/more-equal-than-others"> meet the UN’s Sustainable Development Goals</a> (SDGs) target of 90% institutional delivery rate by 2030.
Wealth inequality and provincial variations, especially in Madhes, pose challenges that need nuanced understanding of women’s reluctance to seek health services.&nbsp;
Despite Nepal’s success in maintaining population growth close to replacement levels, the total fertility rate (TFR) is significantly higher among those without formal education. The proportion of postpartum family planning uptake is also lowest in Madhes and Sudur Paschim at only 0.2%.
Breastfeeding is in decline, with less than three out of five mothers following recommended practices. Regional variations highlight the need for targeted interventions, particularly in provinces like Bagmati, where breastfeeding rates are lower among well-educated city dwellers.&nbsp;
Read Also: <a href="https://nepalitimes.com/here-now/why-has-progress-in-saving-women-s-lives-stalled">Why has progress in saving women’s lives stalled?</a>, Marty Logan
Anemia persists as another risk factor, with Madhes Province again carrying the highest burden.
Comparing Nepal with Bangladesh, India, and Pakistan shows that we are doing better in under-five and infant mortality rates. Nepal’s institutional delivery rate surpasses Bangladesh, but lags slightly behind India.
Even so, alarming disparities persist in neonatal and maternal mortality rates within disadvantaged groups, reflecting inadequate coverage of routine maternal and neonatal health visits and suboptimal care.&nbsp;
This points to both limited access to recommended interventions for disadvantaged women and potential inefficiencies in delivering crucial interventions during routine these visits.
Nepal should prioritise rural pockets of the country and employ a comprehensive strategy that includes delivering antenatal care through primary health care outreach, home visits, distributing essential medicines, vaccinations, and identifying appropriate health facilities for birth preparedness.
Read Also: <a href="https://nepalitimes.com/banner/what-can-be-more-fulfilling-than-saving-lives">“What can be more fulfilling than saving lives?</a>”, Naresh Newar
The quality of antenatal care must be improved by talking about nutrition with pregnant women and families, emphasising awareness of danger signs that necessitate timely health facility visits, and ensuring local governments can efficiently refer complicated cases, with airlifting as a viable option for emergencies.
Adolescent Sexual Reproductive Health with a targeted focus in provinces with early marriages and childbirths combined with education, awareness, and easy access to reproductive health services are imperative.
More effort is needed to meet the SDG target of reducing the MMR to 70 per 100,000 live births. Mitigating disparities among provinces demands political commitment, active local leadership, community engagement, especially leveraging the youth force, and fostering public-private partnerships at all levels.
Surya Bhatta is Executive Director of One Heart Worldwide that works primarily on maternal health in rural Nepal.

original

674x448

610x380

500x500

400x266

400x240

400x203

301x200

1250x600

1084x550

Saving more mothers and babies

Nearly every maternal death is preventable, and the clinical expertise and technology necessary to avert these losses have existed for decades. And yet, elsewhere in the world and in Nepal, progresses in maternal health has stalled in recent years. A new report reveals that from 2000 to 2015, the global maternal mortality ratio (MMR) fell by 33%, and by more than 50% in 58 countries that had the highest rates of women dying during pregnancy or up to 42 days after delivery. But from 2016 to 2020, maternal mortality barely changed. In 2020, roughly 287,000 women globally died from a maternal cause, which is almost 800 maternal deaths daily, and about one every two minutes. The report, Trends in maternal mortality 2000 to 2020: estimates, by United Nations (UN) agencies and the World Bank Group, predicted that if current trends continue more than one million extra maternal deaths will occur by 2030, the end of the global Sustainable Development Goals (SDGs). ‘Health systems must be held accountable for providing quality, respectful and equitable care through a well-trained and supported workforce and well-stocked shelves,’ states WHO Director-General Dr Tedros Adhanom Ghebreyesus in the foreword to the UN /World Bank report. He adds: ‘At the same time, the persistent gender norms that deprioritise the health of women and girls must be addressed, to afford women respect and care during pregnancy and childbirth, along with protecting their right to access high-quality sexual and reproductive health services.’ The 17 SDGs were adopted by all UN member states in 2015 after the Millennium Development Goals (2000-2015) ended. Each SDG deals with a specific development issue, such as poverty, education and health. And every goal includes specific targets, all of which are supposed to be met by 2030. The SDG target (3.1) for maternal mortality is a global MMR of less than 70 for every 100,000 live births. A supplementary target is that by 2030, no country should have an MMR greater than 140. Read also: <a href="https://www.nepalitimes.com/multimedia/mothers-of-sarlahi">Mothers of Sarlahi</a>, Marty Logan  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20230714130748_23f060d961f04e9edea9d7c82e74c6a7658266eeb7e70c50d6a2d4546f60bbc5.jpg" data-media-id="editor_1" data-image-id="20230714130748_23f060d961f04e9edea9d7c82e74c6a7658266eeb7e70c50d6a2d4546f60bbc5" data-rendition-name="original" width="1500" height="844" loading="lazy" alt="Maternal mortality"> <figcaption>Photo: MARTY LOGAN</figcaption> </figure>  The global MMR in 2020 was estimated at 223, down from 227 in 2015 and from 339 in 2000 – a drop of one-third (34.3%) from 2000 to 2020 but far from the target of 70. If the pace of progress seen in 2016–2020 continues, the MMR will be 222 by 2030 – over three times the target. The vast majority of maternal deaths are preventable: the clinical knowledge and technology needed to prevent them have long existed. But, such solutions are often not available, not accessible or not put in place, says the report. This is especially true in locations lacking resources and/or among populations that are at greater risk because of so-called ‘social determinants’ — for instance, their economic and education levels and distance from health services. In 2020, sub-Saharan Africa was the only region with an MMR that the report labels ‘very high’ (500-999) — 545 maternal deaths per 100 000 live births. A 15-year-old girl in the region had a 1 in 40 lifetime risk of dying from a maternal cause. Sub-Saharan Africa alone accounted for roughly 70% of global maternal deaths in 2020, followed by Central and Southern Asia (17%). Between 2000 and 2020, Central and Southern Asia achieved the greatest percentage drop in MMR, with a decline of 67.5%, falling from 397 to 129 maternal deaths per 100 000 live births. In 2020, MMR was lowest in Australia and New Zealand. A 15-year-old girl there had a 1 in 16,000 lifetime risk of dying from a maternal cause. Nepal saw one of the most dramatic progresses in maternal health. Between 1996 and 2016, the MMR decreased from 539 to 239 only for the progress to plateaued off in the recent years. National Population and Housing Census 2021 puts MMR currently at 151 per 100,000 live births against the target of 115. In the United States the MMR soared between 2018 and 2021, from 17.4 per 100,000 live births to 32.9, according to the US Centers for Disease Control and Prevention. During the same period, the MMR for the Black population went from 37.3 to 69.9. For the White population it started at 14.9 in 2018 and rose to 26.6 in 2021. Many experts point to impacts of Covid-19 as a main cause of the spike, and an article by CNN also notes that the MMR has been steadily rising in the US for three decades. Read also: <a href="https://www.nepalitimes.com/opinion/midwives-to-the-rescue-in-nepal">Midwives to the rescue in Nepal</a>, Laxmi Tamang  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20230714130748_863bee8d50247bb6c866aa75c90f9f422380829ddf7460e773ea836951fcc532.jpg" data-media-id="editor_3" data-image-id="20230714130748_863bee8d50247bb6c866aa75c90f9f422380829ddf7460e773ea836951fcc532" data-rendition-name="original" width="1200" height="800" loading="lazy" alt="Maternal mortality NT"> <figcaption>Photo: PRASANSA BUDHA MAGAR</figcaption> </figure>  In 2021 the US Government introduced policies to address the negative trend, including the Black Maternal “Momnibus” Act of 2021. That package of bills aims to provide pre- and post-natal support for Black mothers, including extending eligibility for certain benefits postpartum, adds the CNN article. “It is plausible” that the pandemic had an impact on maternal mortality, says the UN/World Bank report, while noting that stagnation in progress started before 2020, when Covid-19 spread globally. Studies in four countries have found excess maternal mortality due to the pandemic but research is scarce. The report says multisectoral action is needed to meet various challenges to reducing maternal mortality, including: <ul> <li>Strengthen health systems by: increasing numbers of well-trained and supervised staff; tackling shortages of essential supplies and making them accountable to ensuring the rights of women and girls;</li> <li>Focus on improving access to women and girls marginalized by social determinants, including: ethnicity, age, disability and socioeconomic inequalities, which impede women’s access to and use of sexual and reproductive health services;</li> <li>Achieve universal health coverage so that services are affordable;</li> <li>A perspective that embraces women’s equality and human rights must animate action;</li> <li>Health systems must be made more resilient to climate and humanitarian crises.</li> </ul> “A woman’s health lays the foundation for her children’s health, her family, her community and for generations to come,” says the World Economic Forum. Gender equality globally would raise the world’s gross domestic product as much as US$28 billion, it adds. Read also: <a href="https://www.nepalitimes.com/banner/balancing-life-and-death-in-nepal/">Balancing life and death in Nepal</a>, Ashmita Hamal and Naresh Newar Reprinted under an arrangement with Inter Press Service (IPS).

Marty Logan

Why has progress in saving women’s lives stalled?

<figure><img width="1198" height="679" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114111144/63721c059c7e80680e0bd46djpeg.jpg" alt=""/><figcaption> Locals from Budhinanda in Bajura transporting a woman in labour to a hospital in district headquarters. All photos: PRAKASH SINGH</figcaption></figure><img width="1456" height="589" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114111144/63721c079c7e80680e0bd46ejpeg.jpg" alt="">Nothing could be more symbolic of the misplaced priorities of all three tiers of government in Nepal than the sight of women giving birth by the wayside at a time when politicians are <a href="https://www.nepalitimes.com/latest/nepals-shortsighted-view-tower-craze/">inaugurating yet another view-tower</a> in a lavish function.As a reporter based in Bajura district in Nepal’s rugged northwestern mountains, I have see many mothers with complicated pregnancies being carried on stretchers to hospitals. Usually, they are women who have been in prolonged and agonising labour. Many do not make it, and die along the way. I was working on a story on maternal mortality when I came across a photograph from four years ago of a woman giving birth along a trail. I tweeted it on 26 March, and the image immediately went viral because it coincided with the inauguration by Pushpa Kamal Dahal of a nine-storey view-tower in Rolpa district.<blockquote>बाटोमा यसरी बच्चा जन्माउछन्, दुर्गमका महिला <a href="https://t.co/sZfmFmzv3F">pic.twitter.com/sZfmFmzv3F</a>— Prakash Singh (@prakashbajura) <a href="https://twitter.com/prakashbajura/status/1507590311073230853?ref_src=twsrc%5Etfw">March 26, 2022</a></blockquote> Even though that photograph was from some years ago, the situation with maternal and infant deaths in Bajura has not improved. For Nepal’s netizens, that symbol of neglect was in stark contrast with the view-tower building spree across the country. In fact Bajura has one of the worst socio-economic and health indicators in Nepal. Just in the past three years, eight women with difficult pregnancies have died while being transported to the district’s only hospital in Martadi. These were just ones that were officially recorded, there are surely many more mothers in far-flung villages of this district who did not make it.Read more: <a href="https://www.nepalitimes.com/here-now/grassroots-democracy-promotes-good-health/">Grassroots democracy promotes good health</a>, Sagar BudathokiThe mother and baby in my photograph that went viral in social media were the lucky ones. The mother’s name was Tara Luhar from Budiganga Municipality, and after running into them on a village trail, I took the photo after taking their consent.   Although heavily pregnant, Tara had been doing all household chores herself, including raising her other children and taking care of the livestock and farm. No female community health volunteer had visited her home and she did not know that she needed pre-natal checkups, and the need to deliver in a health post or hospital. Most women in Bajura’s traditional families are <a href="https://www.nepalitimes.com/here-now/the-curse-of-being-new-mothers/">banished to cowsheds during childbirth</a>. It was only when her labour dragged on for four days that neighbours and relatives decided to carry Tara to the health post in a stretcher. During the journey lasting several hours, the baby came out and into the dusty trail. Tara simply carried her baby, and walked back home.  This week, after the photograph made her famous, I called Tara Luhar. She said the baby was now four years old and they were both were healthy. Her husband, who was working in India, had died at about the time her son was born. As single mother, she now struggles to make ends meet.“Most of our births in Bajura are at home, there are very few institutional deliveries,” explains Bimala Pandey of the Bichchyan Health Post in Bajura. “There are many cases of women giving birth while on their way. We have to refer the complicated cases to Achham.”  Nepal has taken dramatic strides in reducing its maternal mortality ratio (MMR). It has come down from 880 per 100,000 live births in 1980 to less than 200 in 2019. But maternal deaths have gone up again in the past two years because of the drop in institutional <a href="https://www.nepalitimes.com/here-now/birth-and-death-during-a-pandemic/">deliveries during the pandemic.</a> Bajura’s maternal mortality ratio in 2014 was much higher than the national average: 380. The district ranks at the bottom among Nepal’s districts in the Human Development Index (HDI), with just 0.364 against a national average of 0.602 in 2019. The infant mortality ratio has improved, but is still at 27 deaths per 1,000, mainly babies who die within a month of being born.Although the photograph of the mother giving birth by the side of the road sparked outrage on Nepal’s cybersphere, for Bajura it was just another tragic reminder of its poor state of healthcare. Three <a href="https://www.nepalitimes.com/latest/3-nepali-mothers-still-die-daily-at-childbirth/">mothers die at childbirth every day</a> in Nepal, and in Bajura there is not a month that goes by without news of yet another mother who does not make it while giving birth by the roadside. <figure><img width="1200" height="681" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114111144/63721c0b9c7e80680e0bd46fjpeg.jpg" alt=""><figcaption>Bajura's Nitikhola resident Parvati Budha, 23, delivering a baby on the way.</figcaption></figure>The <a href="https://www.nepalitimes.com/here-now/who-will-save-nepals-poor-new-mothers/">high cost of ambulance</a> and lack of political connections to get medical evacuation by helicopter under the <a href="https://www.nepalitimes.com/here-now/nepals-air-ambulance-saves-mothers/">President’s Program for Women’s Upliftment</a>, most families have to physically carry pregnant women with complicated pregnancies. Last month, 23-year-old Parbati Buda of Himal Rural Municpality had her baby while being carried for over six hours to the local health post. Buda was lucky to survive. In the past year two women died while being carried to Achham – the travel by stretcher and jeep took too long, and the family had waited till it was too late to save them.Because local health posts are not properly equipped to deal with births in which a caesaerian section may be required, many families try to take them to <a href="http://archive.nepalitimes.com/regular-columns/GUEST-COLUMN/Saving-one-mother-at-a-time,816">Bayalpata Hosptial in adjoining Achham district</a>, which has a dedicated maternity ward and surgery.Read more: <a href="https://www.nepalitimes.com/banner/this-is-how-to-upgrade-nepals-rural-health/">This is how to upgrade Nepal’s rural health</a>, Sewa BhattaraiPrakash Singh is editor in chief of Badimalika Khabar in Bajura.<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114111144/63721c0e9c7e80680e0bd470jpeg.jpg" alt="" width="120" height="150">

Born by the roadside in Nepal

Tranexamic acid (TXA) is a game-changer drug in the treatment of post-partum haemorrhage (PPH), the main cause of death in women immediately after giving birth.Unsurprisingly, 99 % of these deaths occur in under-developed countries like Nepal because many patients cannot afford treatment. The good news is that TXA is inexpensive, and is widely available in South Asia.<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109101136/636b75419c7e80680e0623ddjpeg.jpg" alt="" width="800" height="479"/>Most doctors, especially those who work in emergency room settings, have certainly heard about this drug and probably use it often. The drug’s scope is clearly not limited to PPH: it is very often used in trauma victims to stem bleeding.Read also: <a href="https://www.nepalitimes.com/?p=41024&amp;preview_nonce=ec84b2062a&amp;preview=true" target="_blank" rel="noopener">No conceivable reason for unwanted pregnancies</a> <a href="https://www.nepalitimes.com/here-now/who-will-save-nepals-poor-new-mothers/">Who will save Nepal’s poor pregnant women … a government plan, or God?</a>, Rojita AdhikariHowever, many doctors, <a href="https://www.figo.org/news/save-mothers-stop-PPH" target="_blank" rel="noopener">including those in obstetrics and gynecology</a>, may not know why exactly this well-known and often-used drug has recently shot to prominence in the treatment  of  PPH.It all had to do with the <a href="https://www.lshtm.ac.uk/newsevents/news/2017/every-minute-counts-when-using-lifesaving-drug-treat-bleeding" target="_blank" rel="noopener">WOMAN study</a>. In order to avoid unnecessary bias regarding drug recommendations, Western medicine is generally based on randomised, double-blind, placebo-controlled trials called RCT (randomised controlled trials).These rigorous methods are applied so that the final results will have as little to do with chance as possible. (In fact this year’s Nobel Prize in economy went to a couple, Banerjee and Duflo,who used the RCT method to arrive at their conclusions on alleviating global poverty.)For the <a href="https://sinaiem.org/txa-in-the-hemorrhaging-postpartum-patient/" target="_blank" rel="noopener">TXA study,</a> the investigators recruited women aged 16 years and older with a clinical diagnosis of <a href="https://www.medpagetoday.com/meetingcoverage/smfm/70933" target="_blank" rel="noopener">post-partum hemorrhage after vaginal birth or caesarian section</a> from 193 hospitals in 21 countries, including BPKIHS and Birat Hospital in Dharan and Nepal Medical College in Kathmandu.Read also: <a href="https://www.nepalitimes.com/here-now/nepal-far-from-hitting-contraceptive-target/" target="_blank" rel="noopener">Nepal far from hitting contraceptive target</a>, Sewa BhattaraiBetween March, 2010 and April 2016, 20,060 women were randomly assigned by the international panel of study investigators to receive either 1 gram of intravenous TXA or a matching  placebo (a look-alike sugar pill) in addition to the usual care that included other drugs.The results were ground-breaking. When given within three hours after the onset of PPH, one in three maternal deaths were prevented with TXA. The study was published in the medical journal Lancet in May 2017. The World Health Organization (WHO) took note.<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109101136/636b75439c7e80680e0623dejpeg.jpg" alt="" width="1000" height="562">In fact the WHO had already recommended the use of TXA in PPH back in 2012, but the recommendation at that time was to use TXA almost as a last resort after the uterotonics failed to control the bleeding. Uterotonics are drugs like oxytocin and prostaglandins that are commonly used to contract the uterus to stop haemorrhage. TXA does not work by tightening the uterus but by inhibiting the breakdown of blood clots (fibrin and fibrinogen), a completely different mechanism of action.Read also: <a href="https://archive.nepalitimes.com/article/Nepali-Times-Buzz/globe-rallies-to-aid-nepals-women,3841" target="_blank" rel="noopener">Cutting the lifeline</a>, Kate RyanIn  2017, based on the WOMAN trial (the World Maternal Antifibrionlytic acronym is in keeping with TXA’s mechanism  of action), the WHO put out new recommendations prioritising the use of TXA in the treatment of PPH: to use it as soon as possible with the uterotonics and not to wait and watch.This updated recommendation may not be known to many health care professionals on the frontline of post-partum haemmorhage treatment in Nepal. The use of TXA for a patient with PPH will only succeed if there is the political will to push it. Otherwise this tremendous advancement in medical care will be relegated to the dustbin.Fortunately, the Nepal government may soon be endorsing  new guidelines for the prompt use of TXA, especially in remote health facilities, to further reduce Nepal’s maternal mortality rate.Read also: <a href="http://archive.nepalitimes.com/article/nation/people-politics-placentas-child-delivery-complications,3922" target="_blank" rel="noopener">People, Politics, and Placentas</a>, Bikash GauchanThe prompt use of TXA can also decrease the financially- devastating helicopter rescues that poor Nepali families in far-away districts have to resort to to save the lives of relatives suffering from PPH. Most cannot afford to hire helicopters and bleed to death.In most cases, TXA has to be given intravenously, and since many Nepali births (and deaths) take place at home, this approach may not be feasible. Who is going to put in the intravenous line even if the drug is available and cheap?Amazingly, the tablet form of the drug is already easily available in Nepal, but more research is needed to find out if giving the drug orally will achieve the same result. If TXA  tablets stop post-birth bleeding as injections do, that would be very welcome news for Nepali mothers-to-be.Buddha Basnyat, MD, is a physician at the Patan Academy of Health Sciences and writes on health issues for Nepali Times.

Miracle drug to reduce maternal deaths

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109101136/636b74e99c7e80680e0623bcjpeg.jpg" alt="" width="3600" height="2400"/><figcaption>Nepali students on their way to the quarantine centre in Bhaktapur after landing in Kathmandu Airport on Sunday morning. Photo: RSS</figcaption></figure>The global public health crisis caused by <a href="https://www.nepalitimes.com/banner/why-nepal-must-watch-about-coronavirus-but-not-panic/">the 2019 novel coronavirus </a>has  hospitalised tens of thousands and killed hundreds of people, wrecked tourism in the Asia-Pacific region, impacted civil aviation and slowed down the world economy.An <a href="https://www.theguardian.com/global-development/2020/feb/07/coronavirus-chinese-rage-death-whistleblower-doctor-li-wenliang">attempt by the Chinese authorities to suppress</a> first reports from Wuhan is blamed for the initial rise in case load, and its dissemination across China and the world. But it is also China’s willingness to quarantine a whole province that is stopping its spread.The epidemic has also exposed the challenges to containment in <a href="v">the age of social media</a>. Rumours and conspiracy theories resulting in stigmatisation and xenophobia have become the norm in a global village interconnected instantaneously by internet-based apps.The media’s habit of magnifying the negative is now exacerbated by the split-second reach of individual posts, click-baits, fake news, and the chain-reaction through shares and likes over web platforms.Till Wednesday, 2,012 people had died from <a href="https://www.nepalitimes.com/latest/a-nepali-in-beijing-during-coronavirus-scare/">the Wuhan virus</a>, and 75,227 are hospitalised. These statistics are constantly updated in the media, with countries where it has spread shaded ominously on a world map – giving the impression that it has spread globally.Yet there are very few mentions anywhere that nearly 15,000 infected people have made full recovery, or that the fatality rate for the virus is a low 2%. Even though no one has yet died in the United States from this virus strain, there is saturation coverage in the media that likens the epidemic to the one in the Hollywood thriller Contagion. Few compare Covid-19 to the common flu that killed nearly 35,000 people in the United States last winter.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109101136/636b74eb9c7e80680e0623bdjpeg.jpg" alt="" width="1800" height="1291"><figcaption> </figcaption></figure>The psychology of terror, irrationality of panic, and fear of diseases without cure are not new. What is new this time is mobile communication which allows panic about the virus to go viral.In Nepal, too, the media was obsessed with the plight of 182 students trapped in Hubei province. The issue was politicised by those opposed to Prime Minister Oli’s government – both within his NCP and without. Media gave prominence to tearful parents, highlighted a letter to the prime minister about his callousness and disregard. Under pressure already for non-performance, the government found <a href="https://www.nepalitimes.com/latest/nepalis-from-hubei-quarantined-in-bhaktapur/">the evacuation of the students to a quarantine camp</a> in Bhaktapur a convenient way to show-case action.If only the government reacted with similar efficiency to other, much more serious, national emergencies like Nepal’s unacceptably high maternal mortality rate. Although there has been a steep drop in the number of women who die in childbirth from 900 per 100,000 in 1990 to 239 today, Nepal has <a href="https://www.nepalitimes.com/banner/federalism-leaves-nepals-medical-sector-ailing/">missed the target</a> of reducing that number to 125 this year. It does not look like we will hit the SDG goal of 75 by 2030, either.<a href="https://www.nepalitimes.com/here-now/who-will-save-nepals-poor-new-mothers/">More than 1,200 women die</a> in child birth every year in Nepal, that is three every day. Most of these are easily preventable either by ensuring proper nutrition, enforcing the ban on <a href="https://www.nepalitimes.com/banner/child-marriage-in-nepal-eloped-at-13-mother-by-17/">child marriage</a>, ensuring access to ultrasound machines to detect complications in time, and encouraging institutional delivery.As Buddha Basnyat of the Patan Academy of Health Sciences (PAHS) comments, it is only political will that is stopping Nepal from adopting the game-changer drug Tranexamic acid (TXA) in the treatment of post-partum haemorrhage, (PPH) the most common cause of maternal death. There is a huge 44% <a href="https://www.nepalitimes.com/here-now/nepal-far-from-hitting-contraceptive-target/">unmet need for contraceptives</a>, which is leading to unwanted pregnancies and preventing a further drop in Nepal’s total fertility rate.<a href="https://www.nepalitimes.com/banner/tb/">Tuberculosis</a> kills 6,000 people in Nepal every year, and every other Nepali is a carrier of the bacillus, which means half the population should actually be quarantined. Yet the health system is supremely unconcerned, and the public is not aware of the risk.There were 2,736 fatalities in <a href="https://www.nepalitimes.com/banner/nepals-deadly-roads-take-their-toll/">road traffic accidents</a> in Nepal last year. Yet, even though the coronavirus has not killed anyone and there has been only one suspected case, Nepalis are hoarding supplies of masks and hand sanitisers. Meanwhile, vehicles continued to be driven recklessly over precarious roads. Where is the outrage?<a href="https://www.nepalitimes.com/here-now/air-pollution-is-more-dangerous-than-smoking/">Air pollution</a> in Kathmandu Valley, Chitwan and the Tarai is so bad that it is making many people die prematurely, reducing our lifespans by 3.5 years. Where is the peoples’ anger at having their lives cut short? It is ironic that residents of Kharipati are more worried about Nepali students from Wuhan being quarantined in their neighbourhood, than about the toxic fumes emitted by dozens of brick kilns nearby.To be sure, we cannot afford to be complacent when it comes to new epidemics like <a href="v">Covid-19</a>. However, it is the neglect of easily preventable diseases that kills more people in Nepal -- most often poor people in rural communities. We need a robust health system that prioritises primary health care, trains medical professionals, and builds a well-equipped infrastructure to handle future epidemics.But that does not make it into the news.Sonia Awale

Sonia Awale

When panic goes viral

https://youtu.be/FmieAvLuWBoFederalism was supposed to bring the government closer to the people, decentralise medical care and improve <a href="https://www.nepalitimes.com/editorial/poor-health/" target="_blank" rel="noopener">public health</a> at the grassroots. But the new three-tier government structure threatens to undo Nepal’s gains in improving health services.The government’s ‘adjustment policy’ in the medical sector, which lets staff to pick their preferred tier of work, has led many to choose the federal level, leaving provinces and municipalities underserved. The biggest losers are the areas already lacking in services: Province 6 (Karnali) and the Far Western Province.Read also: <a style="background-color: #ffffff; font-size: 15px; letter-spacing: 0.01em;" href="https://www.nepalitimes.com/?p=37757&amp;preview=true" target="_blank" rel="noopener">Poor health makes Nepalis poorer</a>, Editorial At the Kolti Primary Health Care Centre in Bajura, there is no doctor, after the one serving here chose to be transferred to Kathmandu. Bajura District Hospital has five doctors but the contracts of three of them will soon expire.“I have not been informed of my new hospital yet, but I am about to be transferred. In two months, there will be a shortage of doctors here,” predicts Chief Medical Officer Rup Chandra BK, adding that all technicians, including a paramedic, a radiographer and health assistants, have been transferred or will be soon.Read also: <a href="https://www.nepalitimes.com/opinion/is-free-health-care-possible-in-nepal/" target="_blank" rel="noopener">Is free health care possible in Nepal?</a>, S P Kalaunee <a href="https://www.nepalitimes.com/banner/this-is-how-to-upgrade-nepals-rural-health/" target="_blank" rel="noopener">This is how to upgrade Nepal's rural health</a>, Sewa Bhattarai<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221108151124/636a66a79c7e80680e059998jpeg.jpg" alt="" width="640" height="427"/>With a population of 135,000 people, Bajura has no private hospitals and only one government hospital, a primary health care centre, and 26 health posts. WHO recommends a doctor-patient ratio of 1:1,000, but here it is 1:150,000, while Kathmandu has a ratio of 1:850.This is nothing new: Far Western Province has long faced medical staff shortages. According to the Department of Health Services Report 2018, only 80% of positions in health facilities were filled, and only 56 of the 142 sanctioned doctor positions were staffed. That number will decrease further after adjustment.According to a list of adjustments of 8th level general practitioners (GPs) by the ministry of health, 36 doctors were serving in Far Western Province, but only 9 of them have chosen to remain. Of the 631 doctors at this level, as many as 326 chose the federal level, which means they are concentrated in Province 3. It is the same story in all other provinces. There are only 14 doctors in Province 6.“Far Western Province has always faced a shortage of doctors. We have a lot of nurses, assistants, and technicians, and even if they are transferred there are others to replace them. But specialist doctors earn a lot in the cities and a government hospital cannot offer them as much. No wonder they do not want to stay here if they have a choice,” says Ramesh Kunwar at the ministry of social welfare in the province.Read also:<a href="https://www.nepalitimes.com/editorial/poor-health/" target="_blank" rel="noopener">Poor health</a>, Editorial<a href="https://www.nepalitimes.com/here-now/henry-marsh-returns-to-the-institute-created-by-his-neurosurgeon-colleague-upendra-devkota/" target="_blank" rel="noopener">Henry Marsh returns to the institute created by his neurosurgeon colleague Upendra Devkota</a><figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221108151124/636a66a99c7e80680e059999jpeg.jpg" alt="" width="1500" height="1000"><figcaption> </figcaption></figure>The Government Doctors’ Association of Nepal (GODAN) is also unhappy. “From the beginning we have said that the medical sector is different from others and adjustment would result in neglect of underserved regions and migration of doctors to the cities, and we were right,” says Dipendra Pandey, president of GODAN. “We proposed that a federal bridge should be created, so that medical professionals working at the federal level can be sent back to their previous working area.”Ironically<a href="https://www.nepalitimes.com/banner/risking-his-life-to-save-lives/" target="_blank" rel="noopener">, physician Govinda KC</a> had to call off his 17th fast unto death in Dadeldhura because the district hospital did not have proper facilities in case his health deteriorated. KC has been protesting the commercialisation of medical education, which forces doctors to work in the cities to recoup their investments.“If the government does not replace those who are leaving the province, there is going to be a great crisis in healthcare in the Far West,” says Gunaraj Awasthi, chief of the Far West Regional Health Directorate in Dipayal. “It should immediately reinstitute those medical professionals on contract service.”<h2>Neglect kills mothers</h2><figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221108151124/636a66ad9c7e80680e05999ajpeg.jpg" alt="" width="640" height="427"><figcaption> </figcaption></figure>Lalita Bohora, 27, was ten months pregnant when her husband helped her walk for three days from Kolti to Bajura District Hospital to deliver her baby earlier this year. The staff told her it was a complicated pregnancy and there were no doctors to perform a caesariean section.Bohora was lucky — many other mothers are in no position to walk to the district hospital. Although Nepal’s maternal mortality rate (MMR) has come down drastically from 600 per 100,000 live births two decades ago to 239 today, many mothers in remote districts like Bajura continue to <a href="http://archive.nepalitimes.com/article/nation/people-politics-placentas-child-delivery-complications,3922" target="_blank" rel="noopener">lose their lives</a> just because maternity wards are not staffed, or properly equipped.Read also: <a href="http://archive.nepalitimes.com/article/nation/people-politics-placentas-child-delivery-complications,3922" target="_blank" rel="noopener">People, Politics, and Placentas</a>, Bikrash Gauchan<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221108151124/636a66b09c7e80680e05999bjpeg.jpg" alt="" width="643" height="376">Since it started in 1997, the government’s safe motherhood program has provided cash to mothers if they do all four antenatal checkups, and mothers, and medical staff, are given cash incentives for institutional delivery. The number of birthing centres staffed by at least one skilled birth attendant has reached 1,755 nationwide.Despite the progress, Nepal is unlikely to bring MMR down to 125 by next year as planned, or meet the Sustainable Development Goal (SDG) target of 70 by 2030. Nepal’s topography and lack of roads are not the only reasons progress in MMR has stalled. According to a recent survey, half of public health facilities in Nepal lack running water and electricity at all times.Bajura District Hospital is constructing a new building, but it still operates out of an old, partly demolished building, where the operation theatre is a tin shed and there is irregular water supply and  electricity.“We hook up machines to the power supply during complicated operations, and the electricity suddenly goes off — we have to improvise a lot here,” says surgeon Durga Maharjan.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221108151124/636a66b19c7e80680e05999cjpeg.jpg" alt="" width="640" height="427"></figure>Ward at Bajura District HospitalHaemorrhage during birth used to be the biggest cause of maternal mortality in the 1990s, now it is hospital-borne infections like sepsis. Many older women still think babies should be born at home, and dissuade their daughters-in-law from giving birth at a health facility.“There is still the idea that childbirth is a normal, natural thing, and not something you need to visit a hospital for,” says Latika Maskey at the UN Population Fund (UNFPA).Only 30% of women in Bajura go for all four of the antenatal checkups, while the average for the Far West region is 55%, and nationally it is still a high 44%. Because settlements are scattered in roadless remote Nepal, the government has focused on basic health facilities and birthing centres instead of large well-equipped hospitals, explains Punya Poudel at the safe motherhood program in the ministry of health.“We have a roadmap to reduce MMR to 70 by 2030 by focusing on postnatal checkups, midwives will be trained for delivery and community nurses will visit women at home during ante and postnatal periods,” says Poudel.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221108151124/636a66b49c7e80680e05999djpeg.jpg" alt="" width="640" height="427"><figcaption> </figcaption></figure>However, many of the new birthing centres are near bigger health facilities, which makes them less useful. There is a concern among health professionals that populist agendas have fuelled construction sprees, and that the birthing centres are not always staffed and ready to provide service.“Simply building birthing centres is not the solution. They should be properly mapped and located where they will be most effective. They should be functional so that at least one person is available 24 hours a day to provide simple delivery services,” says Pavan Agarwal at Bayalpata Hospital in nearby Achham district.Neetu Shrestha of UNFPA says reproductive health should not be limited to treatment of birth as an event. She says: “To improve maternal health, we need to focus on sex education, invest in <a href="https://www.nepalitimes.com/here-now/nepal-far-from-hitting-contraceptive-target/" target="_blank" rel="noopener">family planning</a> knowledge and methods, ante and post-natal care, and address cultural barriers.”

Federalism leaves Nepal’s medical sector ailing

Nepal’s only international aviation gateway, at Kathmandu airport, will cut night-time operation hours to allow construction of taxiways, and airlines have been told to curtail flights. This is expected to lead to more than normal chaos during the height of peak autumn and spring tourist seasons at an airport that is congested even at the best of times. The airport will close from 10PM to 8AM from 8 November-31 March 2025. The taxiways will now connect to the thresholds at both ends of the runway, making the airport more efficient in handling higher frequencies of landings and takeoffs. The parallel taxiway extension will allow international flights to land every 4 minutes instead of the current every 7 minutes. At present planes have to wait to land until a plane taking off backtracks along the runway.&nbsp; Kathmandu is Nepal’s only airport with international operations, and it has only one runway that is only one way in from the south over the mountains. With the taxiway improvement, the airport will be able to handle 42 aircraft landings and takeoffs per hour — double the current capacity.&nbsp; The Civil Aviation Authority of Nepal (CAAN) has been trying to entice international airlines to also start flying to and from the other two international airports at Pokhara and Bhairawa (Lumbini) by slashing landing and handling charges. But so far only Nepal Airlines operates a weekly flight to Bhairawa from Kuala Lumpur.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20241018161016_046569e53d1d66cd445cc66c697c0ef724810aec9f54bdf827481e3cd6b80c32.jpg" data-media-id="editor_0" data-image-id="20241018161016_046569e53d1d66cd445cc66c697c0ef724810aec9f54bdf827481e3cd6b80c32" data-rendition-name="original" width="2356" height="1134" loading="lazy" alt="Kathmandu airport expansion"> <figcaption>Kathmandu Airport Expansion plan with extension of taxiways to the thresholds of runways 02 and 20 that will limit airport operations from 8 November 2024 - 31 March 2025. Areas in blue are existing structures, including the international terminal which in future will be the domestic airport, and the new international terminal near the north end of the runway,</figcaption> </figure>   <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20241018121028_6e17cc2ee87c1b02d78cb54905825b7aa15299b7a00f5eddb01a59579ab85c1a.jpg" data-media-id="editor_1" data-image-id="20241018121028_6e17cc2ee87c1b02d78cb54905825b7aa15299b7a00f5eddb01a59579ab85c1a" data-rendition-name="original" width="1353" height="1328" loading="lazy" alt="Kathmandu airport NT"> </figure>  CAAN has reportedly told international airlines to cut their flight frequency to Kathmandu citing the shorter operation hours and has told budget airlines to shift some of their flights to Pokhara or Bhairawa, or face cuts. Many airlines currently operate regular flights to and from Kathmandu between 10PM and 8AM: Air Arabia to Sharjah, Fly Dubai to Dubai, Jazeera Airways to Kuwait, Cathay Pacific to Hong Kong, Singapore Airlines, several Nepal Airlines flights, and one of four daily flights by Qatar Airways to Doha. Jazeera Airways, FlyDubai, and Thai AirAsia have applied and got permission from CAAN to begin regular flights to Bhairawa’s Gautam Buddha International Airport. Starting 9 November, FlyDubai will start making a stopover in Bhairawa before flying on to Kathmandu. Immigration, customs and security are all fully functional in Bhairawa. In Kathmandu, the next phase of the airport upgrade includes converting the current international terminal for domestic operations, the construction of a new international terminal where the domestic departure area is now, as well as moving the hangars and the Nepal Army Air Wing to the eastern side of the runway. The apron area will also double its parking space for widebody jets. This is part of a Airport Capacity Enhancement Project that was initially funded through a $80 million loan from the Asian Development Bank (ADB), and the entire masterplan is expected to cost $800 million. This project is the latest upgrade to Nepal’s only international airport since it saw its first flight in 1949. The current international and domestic terminals are too small to handle the current annual traffic volume of 8.5 million passengers a year that is growing at 20% a year.

Kathmandu airport to cut flight hours

As Kathmandu becomes more congested and polluted, and with remote online work becoming the norm, many professional Nepalis are planning to retire in Pokhara, or move there.&nbsp; With its stunning mountain panorama, balmy winters and proximity to a profusion of wilderness areas, builders are responding to this demand with new townhouses, housing development and apartments. One such block of flats is the 10-storey <a href="https://sungavaapartment.com/">Sungava Apartment</a> located at Phulbari above the Seti River, near the point where it flows into and under Pokhara. The imposing structure near Manipal Hospital is almost complete, and on a recent visit the site was strewn with huge boulders unearthed while digging the foundation.&nbsp; The Seti brought down these boulders during a gigantic flood that geologists estimate happened 800 years ago when a chunk of Annapurna IV broke off and ploughed into the glacier below. Today, Sungava (means ‘orchid’) sits safely on a high terrace, 100m above the blue-green Seti and commands a view of Dhaulagiri, Annapurna South, Machapuchre, Annapurna III and IV.&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/2024102411104_5f8fc736c86ea3c08d7bef43bb727081d3cc1a2caa55ae2b441717e6044de7e9.jpg" data-media-id="editor_1" data-image-id="2024102411104_5f8fc736c86ea3c08d7bef43bb727081d3cc1a2caa55ae2b441717e6044de7e9" data-rendition-name="original" width="2016" height="1512" loading="lazy" alt="High living below the Himalaya NT"> </figure>  The soil here is conglomerate that has solidified like concrete, and the boulders were extracted by heavy earthmovers. It is intriguing to think that these metamorphic rocks as big as cars, rounded by glacial grinding, were once a part of a much higher Annapurna IV. Even for those with little interest in geology, Sungava is an ideal place to contemplate the tectonic forces that pushed these peaks into the sky to be sculpted into delicate shapes by wind, snow, earthquake and avalanche over millions of years. The view of the Himalayan panorama from Sungava’s many balconies are breathtaking when not obscured by clouds, or the haze that drifts in from across the southern border. On most days, just watching the towering pyramid of Machapuchre (Tamu name: कतासुँ क्लिको) play hide and seek with the clouds is mesmerising. There are rocks aplenty at Phulbari, and it is probably the flowers that grew along the flat terraces e that gave the place its flowery name. The boulders will hopefully be turned into a rock garden while landscaping. An nearby restaurant complex is making the best use of the stones in its design, using flat rocks as outdoor benches and tables. Sungava was designed by the husband-wife architect team of Deepak Sherchan and Jyoti Joshi of <a href="https://thedarkmermaidamarbshrestha.blogspot.com/2013/12/creative-builders-collaborative-cbc.html">Creative Builders Collaborative (CBC)</a>, which also built Heritage Plaza, Indreni Apartment and numerous other projects in Nepal. Sadbhavana retains CBC’s trademark Newari-style masonry and here it borrows from the orange brickwork of the old town of Pokhara, integrating it with modern design elements. A few of those heritage houses are still standing in Ganesh Tole and Ram Krishna Tole in Pokhara’s old quarter.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/2024102411108_5eb64a4885961b6d30781cefeb1e8a313da313ac5227c7a66b60f0c7d48d6fab.jpg" data-media-id="editor_3" data-image-id="2024102411108_5eb64a4885961b6d30781cefeb1e8a313da313ac5227c7a66b60f0c7d48d6fab" data-rendition-name="original" width="1362" height="595" loading="lazy" alt="High living below the Himalaya NT"> </figure>  About 400m from the apartment past a bend on the river, and down below three tiers of terraces in the canyon is a suspension bridge. Below it, the Seti is still swollen with post-monsoon flow as it tumbles away in a hurry to head down south.&nbsp; Back at the apartment, it is quiet, far away from the hubbub of Lakeside a 15 minute drive away, and in the lap of greenery. There are 52 units at Sungava and it already has a close-knit prospective community of professionals, including doctors, publishers, engineers, and businesspeople from the renewable energy and IT sectors.&nbsp; Some residents say they opted for a second home in Pokhara to make it a ‘base camp’ to explore the Annapurnas with its many hiking trails made newly accessible with new roads. With the NRN citizenship law, overseas Nepalis can now also buy the flats. &nbsp; The floor plans include options for north and south-facing 3-bedroom apartments with verandas, and the facility has underground parking has EV charging, heated pool, sauna and gym. There are still some unsold apartments with panoramic views of the mountains and one can imagine oneself at the kitchen with its huge window, humming a ditty while preparing breakfast: “खाना पकाउँ हिमाल हेरेर...”

High living below the Himalaya

When the United Nations held its Summit of the Future at its headquarters in New York in September, many world leaders, including Nepal’s Prime Minister K P Oli, highlighted the effect of climate breakdown in increasing the frequency and intensity of natural disasters. What did not get as much attention was the long term impact of the climate crisis on food production. In fact, heat stress, weather extremes and the consequences on rain-fed agriculture is already being felt worldwide, undermining the chances of the <a href="https://unstats.un.org/sdgs/">UN’s Sustainable Development Goals (SDGs)</a> being met by 2030.&nbsp; The SDG’s 17 targets commit countries like Nepal to reduce poverty and inequality, end malnutrition, protect the natural environment, and ensure that citizens all enjoy health, justice and prosperity without leaving anyone behind.&nbsp; However, besides the impact of climate breakdown on agricultural production, in Nepal the area under cultivation is impacted by urban expansion, falling productivity and the need for expensive inputs like fertiliser and pesticides.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20241019041052_626413c5baf4dae407ac9579231b41daeb51510aa636b75aeb7489d94cca6a62.jpg" data-media-id="editor_1" data-image-id="20241019041052_626413c5baf4dae407ac9579231b41daeb51510aa636b75aeb7489d94cca6a62" data-rendition-name="original" width="999" height="1500" loading="lazy" alt="urban agriculture in Kathmandu"> <figcaption>Kathmandu's urban sprawl is eating into its fertile cultivable lands. Photo: TAYLOR MASON</figcaption> </figure>  Now, a new study led by Nepali researcher Prajal Pradhan at the University of Groningen in The Netherlands looks at how urban agriculture may offer a solution to falling food production and meeting SDG targets. The researchers evaluated 1,450 publications exploring the contributions of urban agriculture with both positive and negative effects, and published their findings in the journal Cells Report Sustainability. Urban agriculture can help achieve 17 SDGs, positively influencing 81 targets. However, it could also undermine 51 goals.&nbsp; Read also: <a href="https://nepalitimes.com/here-now/the-vanishing-land">The vanishing land</a>, Taylor Mason “Urban agriculture offers immense potential for sustainable development, but realising this potential depends crucially on adopting practices that minimise its adverse effects while maximising its benefits,” Pradhan explains. Urban agriculture can substantially enhance urban food security, provide employment to the urban poor, serve as ground water recharge in built-up areas, and preserve open spaces that can serve as safe havens during disasters like earthquakes. However, it also presents problems like the potential health risks from contamination and the need for expensive inputs. &nbsp; “Urban agriculture plays a definitive role in advancing the SDGs, but achieving this requires tailored, context-specific solutions that address the unique challenges of different regions,” says Yuanchao Hu of Wuhan University in China and who is a researcher at the Potsdam Institute for Climate Impact Research. “But it needs equitable access and rigorous management of environmental risks.”&nbsp; Rapid urbanisation is eating into Nepal’s most fertile agricultural land, which means farming in remaining open spaces inside cities can be a viable alternative, especially as food prices rise.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20241019041052_7b7c9413086226fbdc630d45acf772cfa1ced77a8970b9056ec5ec7e5226fdf8.jpg" data-media-id="editor_3" data-image-id="20241019041052_7b7c9413086226fbdc630d45acf772cfa1ced77a8970b9056ec5ec7e5226fdf8" data-rendition-name="original" width="1500" height="999" loading="lazy" alt="urban agriculture in Kathmandu"> <figcaption>A vegetable patch in between new houses in Thimi. Photo: TAYLOR MASON</figcaption> </figure>  “The conversion of Nepal’s most fertile land into cities is a severe problem,” Pradhan told Nepali Times. “Crop cultivation, horticulture, agroforestry, beekeeping, livestock rearing, or aquaculture can all be farming activities within and around cities.”&nbsp; The study makes recommendations for sustainable practices that build on the positive aspects of urban agriculture while mitigating the downsides, thereby promoting more resilient cities in future. Research shows that urban agriculture has been helping many countries attain SDG targets by enhancing food security and biodiversity while helping education and preservation of open spaces.&nbsp; Indeed, many farmers from the hinterland who have settled in Kathmandu Valley or other urban areas of the country have been practicing urban agriculture, leasing neighbourhood patches or cultivating roof gardens both out of necessity because of inflation and falling income to grow their own food, and also as a fulfilling hobby. Saurav Dhakal, a sustainability advocate with Story Cycle and now research fellow at the Asian Institute of Technology in Thailand, says there are socio-economic and environmental benefits of urban agriculture. “It provides benefits to all urban dwellers, regardless of their income status,” says Dhakal, “families get fresh food, and there are many other benefits like water retention, heat regulation and biodiversity. These are all public goods, so special government incentives may be needed.” It is not unusual to see vegetable patches and even paddy fields within inner city Kathmandu where an older generation of farmers are using available fertile land and <a href="https://archive.nepalitimes.com/article/Nepali-Times-Buzz/rooftop-gardens-kathmandu,1415">roof gardens to produce fresh, nutritious food </a>to reduce their dependence on food items that have to be bought after being trucked in from large distances.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/2024101905100_1291ce98dbbb8caed8702ac4b1d469b3e13016d7ecaaf3bfd5f91c974d3c0c77.jpg" data-media-id="editor_5" data-image-id="2024101905100_1291ce98dbbb8caed8702ac4b1d469b3e13016d7ecaaf3bfd5f91c974d3c0c77" data-rendition-name="original" width="1500" height="999" loading="lazy" alt="urban agriculture in Kathmandu"> <figcaption>An older generation of farmers are using any available fertile land to continue farming but it is getting more and more difficult. Photo: TAYLOR MASON </figcaption> </figure>  Nepal’s urban population grew rapidly from only 3.6% in 1991 to 25% today. There is large outmigration from the mountains to peri-urban areas of the Tarai, to Kathmandu Valley and Pokhara, with many young men then moving abroad for work. Kathmandu Valley’s population has swelled to nearly 3 million, and is growing at 6.5% a year. Dilip Shrestha, 71, used to work for Nepal Food Corporation, so he knew firsthand about inflation, shortages and vegetables with pesticide residue. So, when he designed his new house in Kathmandu, he built a spacious roof where he grows cucumber, ginger, garlic, coriander, onions, tomatoes, chili, beans, okra, pumpkin and lettuce. His family eats healthier, and he has reduced dependence on the market.&nbsp; The co-author of the Cell Reports Sustainability journal article, Daya Raj Subedi who is a PhD candidate at Beijing Forestry University, says urban agriculture also promotes inclusion and psycho-social wellbeing.&nbsp; He says, “A crucial finding of the study is the identification of opportunities and challenges associated with urban agriculture, it can promote sustainable transformation of society.” In Banepa, 55-year-old Bijaya Manandhar in her lifetime has watched the fertile farms of her neighbourhood that used to supply vegetables to Kathmandu, now completely built up with no open space left. The pandemic lockdown prompted her to turn to the family’s <a href="https://nepalitimes.com/banner/rooftop-agriculture-on-the-roof-of-the-world">ancestral livelihood by growing food</a> not on terrace farms, but on the roof terrace. Manandhar is now a part of <a href="https://nepalitimes.com/banner/rooftop-agriculture-on-the-roof-of-the-world%5C%5C">कौसी खेती र करेसाबारी क्रान्ती</a> (Rooftop Farming and Garden Revolution) which has an online membership of 52,000, and awards annual prizes to women who excel in urban agriculture.&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20241019041052_7257f5def8f823f35a799fa6f6825e153f2ffa406ac11325d4fe74049b79e96d.jpg" data-media-id="editor_8" data-image-id="20241019041052_7257f5def8f823f35a799fa6f6825e153f2ffa406ac11325d4fe74049b79e96d" data-rendition-name="original" width="1600" height="736" loading="lazy" alt="urban agriculture in Kathmandu"> <figcaption>Rooftop farming is gaining popularity as a form of urban agriculture. </figcaption> </figure>   <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20241019041052_beff1a4494ce896dd8fd383ee1f518e5448bcf7ea8bb138255391c7bcb9769ed.jpg" data-media-id="editor_9" data-image-id="20241019041052_beff1a4494ce896dd8fd383ee1f518e5448bcf7ea8bb138255391c7bcb9769ed" data-rendition-name="original" width="4000" height="3000" loading="lazy" alt="urban agriculture in Kathmandu"> </figure>  Pradhan says the challenge now is to upscale such examples of successful urban agricultural practices so they support Neal’s efforts to meet SDG targets. He adds, “Crop cultivation around cities can be protected by land use plans and regulations. Promoting community-based agriculture, including rooftop gardens, requires community engagement and public-private partnerships across the food value chain.”&nbsp; Such support would accelerate the popularity of existing rooftop farming and community gardens in Kathmandu Valley, or kitchen garden initiatives in Pokhara, and building on traditional farming practices that are preserved and integrated into urban settings like in Bhaktapur and Banepa. In Lalitpur, the Women Entrepreneurship Facilitation Center promotes urban farming enhancing both sustainability and empowerment.&nbsp; Another co-author of the report, Yuanchao Hu from China says followup research of the team will aim to identify good practices in local urban agriculture practices. He adds, “There are examples of urban agriculture that optimise sustainability, ensuring that it remains a viable solution for cities globally while countries try to meet SDG targets.” Prajal Pradhan, Daya Raj Subedi, Kshitij Dahal, Yuanchao Hu, Prakriti Gurung, Sijal Pokharel, Sagar Kafle, Biplav Khatri, Sudeeksha Basyal, Monika Gurung, and Aruna Joshi. Urban Agriculture matters for sustainable development. Cell Reports Sustainability, 1:100217, 2024. [DOI: 10.1016/j.crsus.2024.100217] Prajal Pradhan (<a href="mailto:p.pradhan@rug.nl">p.pradhan@rug.nl</a>) This article is brought to you by <a href="https://nepalitimes.com/" target="_blank">Nepali Times</a>, in collaboration with <a href="https://inpsjapan.com/en/" target="_blank">INPS Japan</a> and <a href="https://sgi-peace.org/" target="_blank">Soka Gakkai International</a>, in consultative status with UN ECOSOC.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20240630110640_30c3782f9c09219bf1c249b51483a3cfb7a53a06d117d2aebd23ca7080d12758.jpg" data-media-id="editor_14" data-image-id="20240630110640_30c3782f9c09219bf1c249b51483a3cfb7a53a06d117d2aebd23ca7080d12758" data-rendition-name="original" width="680" height="103" loading="lazy" alt="SDG logo"> </figure>

Back to the land in the cities

The 700-year-old Lakshmi Narasingha temple in Bhaktapur houses a rare half-lion and half-human incarnation of Lord Vishnu carrying the Goddess Lakshmi. The temple was destroyed in the 1934 mega earthquake that killed 10,000 people and destroyed many monuments in Kathmandu Valley. It was rebuilt by a German project in the 1980s, but as a single-storey structure instead of its original two-tier pagoda design.&nbsp; With new findings from in-depth research, Bhaktapur municipality began re-restoring the temple in 2021, preserving its original architecture.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20241017131016_2fae38cce543ad7b1f6de632feb3e212e08ed1acedd747830e949d7b8e878f18.jpg" data-media-id="editor_0" data-image-id="20241017131016_2fae38cce543ad7b1f6de632feb3e212e08ed1acedd747830e949d7b8e878f18" data-rendition-name="original" width="2048" height="1365" loading="lazy" alt="In with the old in Nepal NT"> </figure>  “Our temples and heritage sites hold deep meaning. It is disheartening to witness how often they lose their original elements, whether by design or accident,” explains Kumar Chawal of the Consumer Committee of Bhaktapur. “There is a need to preserve our architecture and protect its historical value for future generations. Otherwise, we risk losing a vital part of our identity.” The Laksmi Narsingha restoration is similar to the Bhai Dega temple in Patan Darbar Square which also collapsed in 1934, but was rebuilt with a Moghul-style dome by the Rana government at the time. Only two months before the 2015 earthquake, heritage conservationists had started to rebuild Bhai Dega as the original three-tier based on early photographs. But priorities shifted when four other temples in the square were brought down by the 7.8M earthquake on 25 April 2015.&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20241017131016_697ea707d9ad163be5de5f2efbf5b70d3cab771adcc22f0fae6bf937c6cb0130.jpg" data-media-id="editor_1" data-image-id="20241017131016_697ea707d9ad163be5de5f2efbf5b70d3cab771adcc22f0fae6bf937c6cb0130" data-rendition-name="original" width="2048" height="1365" loading="lazy" alt="In with the old in Nepal NT"> </figure>  This showed how damage to monuments in Kathmandu Valley spanned from one earthquake to the next. Bhai Dega restoration remains half-complete to this day because money for its restoration ran out.&nbsp; Whereas Bhai Dega restoration was done by the Kathmandu Valley Preservation Trust with grants from western embassies and international foundations, in Bhaktapur it is the municipality itself that allocated the Rs30.7 million needed to restore the Lakshmi Narasingha temple. The expected date of completion is early 2025. The municipality and local communities are focusing on two main aspects: preserving the past and promoting localisation. The restoration team has designed a blueprint for the temple by using historical photographs and insights from older generations.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20241017131016_182882fdc393c99e70d1d0490319e415229563666c4934e3a582426ebf00ca30.jpg" data-media-id="editor_2" data-image-id="20241017131016_182882fdc393c99e70d1d0490319e415229563666c4934e3a582426ebf00ca30" data-rendition-name="original" width="1200" height="560" loading="lazy" alt="In with the old in Nepal NT"> </figure>  “At first, the Lakshmi Narasingha temple had only one entrance, but during the demolition process, we uncovered the foundations of four doors. Now, we are restoring all of them. This is an example of how our ancient structures have changed over time, often without our knowledge,” says Chawal. “Constructing temples is not like building houses. They carry historical and spiritual values, which is why they hold a special place in our hearts,” he adds. By replicating ancient design elements and rebuilding the temple as accurately as possible to its original form, the team has stayed true to Bhaktapur’s soul. But the restoration also revived ancient techniques that were in danger of being forgotten, generating employment for woodcarvers, masons, and contractors. The community of Bhaktapur’s Gahiti neighbourhood near the famous Nyatapola Temple has also set aside specific days for locals to volunteer in the reconstruction work. This has encouraged young people to take pride in ownership of their heritage. Families have also supported the effort by donating funds for bells, the temple pinnacle, and other structural features to the temple.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20241017131016_db850ec0c084cdbe54f65bee92dad2ad8122d20fd60ec87ec086fbb9d2f72bd6.jpg" data-media-id="editor_3" data-image-id="20241017131016_db850ec0c084cdbe54f65bee92dad2ad8122d20fd60ec87ec086fbb9d2f72bd6" data-rendition-name="original" width="2048" height="1365" loading="lazy" alt="In with the old in Nepal NT"> </figure>  “I feel at peace knowing I have contributed my sweat to restoring this temple,” said one volunteer. “It is our duty to preserve our temples and heritage. The Nyatapola area will look magical once this temple is completed.” Community mobilisation is a long-standing tradition in Bhaktapur. In the past, locals have actively participated in the restoration of other temples in the city, such as Bhairav and Nyatapola fostering a strong sense of ownership. This collective engagement has not only been crucial in preserving the city's historical monuments but also in strengthening the bond between local communities and their heritage, says officials at the municipality. While securing funding is essential, and the municipality showed it values heritage conservation, the Lakshmi Narasingha restoration is proof that active involvement and sense of responsibility of the local community is as important, if not more. Local involvement also means that the monuments will be cared for into the future, When locals take ownership of these efforts, the restored monuments are not only protected in the present but are also cared for in the future.

maternal-mortality-rate