<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114101148/63720f509c7e80680e0b796ajpeg.jpg" alt="" width="3000" height="2000"/><figcaption>Photo: NISSI THAPA</figcaption></figure>Over 600,000 <a href="https://www.nepalitimes.com/banner/no-conceivable-reason-for-unwanted-pregnancies/" target="_blank" rel="noopener noreferrer">pregnancies in Nepal in 2017 were unintended</a>, close to two-third of which ended in abortion, reveals a new report released this week by the UNFPA, the United Nations sexual and reproductive health agency aimed at shedding light on the often neglected health crisis affecting women of reproductive age worldwide.The State of World Population 2022 report titled Seeing the Unseen also estimated that nearly half of all global pregnancies, totalling 121 million each year, are unintended and that 'for the women and girls affected, the most life-altering reproductive choice — whether or not to become pregnant — is no choice at all.'“This report is a wakeup call. The staggering number of unintended pregnancies represents a global failure to uphold women and girls’ basic human rights,” says UNFPA Executive Director Natalia Kanem. “Our report reveals that rates of unintended pregnancy strongly correlate with gender inequality, with lower socioeconomic development, and with more restrictions on sexual and reproductive rights.”The report further states that over 60% of unintended pregnancies end in abortion and an estimated 45% of all <a href="https://archive.nepalitimes.com/article/Nepali-Times-Buzz/globe-rallies-to-aid-nepals-women,3841" target="_blank" rel="noopener noreferrer">abortions are unsafe</a>, responsible for 5-13% of all maternal deaths. After taking dramatic strides to reduce maternal mortality rate from 539 per 100,000 live births to 239 between 1996 to 2016, Nepal’s progress has since stagnated, further affected by the pandemic in the last two years.Some 44% of Nepali women of reproductive age who want to avoid pregnancy do not use any contraceptive methods. Similarly, use of modern methods of birth control among married women of reproductive age stands at 43%, leading to high rates of unintended pregnancy and unsafe abortion, while 50% of those who do use contraceptives discontinue within a year. Prevalent gender norms that <a href="https://www.nepalitimes.com/here-now/nepal-far-from-hitting-contraceptive-target/" target="_blank" rel="noopener noreferrer">prevent women and girls from accessing reproductive health care</a> including contraceptives have been identified as a key factor.In addition, half of all pregnancies among adolescents are estimated to be unintended, as only 23% in the group are reported to use contraceptives -- much lower compared to the national average of 43%.Read also: <a href="https://www.nepalitimes.com/banner/lets-talk-about-it/" target="_blank" rel="noopener noreferrer">Let’s talk about it</a>, Duksangh SherpaThe report further states that for every additional dollar spent on <a href="https://www.nepalitimes.com/banner/implant-service-providers-take-contraception-to-nepals-poor/" target="_blank" rel="noopener noreferrer">expanding modern contraceptive use</a>, Nepal would save $2 on maternal and newborn care as a result of fewer unintended births, induced abortions and maternal deaths."The perception among some policy makers that investing in family planning is no longer necessary due to the decline is fertility in Nepal is very concerning," says Lubna Baqi, UNFPA Country Representative, "as it does not take into account the high levels of unmet need for family planning, which currently stands at 24%, and the high rates of unintended pregnancies, and unsafe abortions that take place because of the gaps in services.”<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114101148/63720f549c7e80680e0b796bjpeg.jpg" alt="" width="960" height="1216">Women and girls from minority groups face further challenges and discrimination in accessing services and information. Given that <a href="https://www.nepalitimes.com/nepali-times-search/?q=child+marriage" target="_blank" rel="noopener noreferrer">child marriage is still prevalent</a> in Nepal with nearly 41% of adolescents married before 18, adolescent girls are at a higher risk.Abortion services on the other hand are largely unsafe. Despite being legalised in 2002, majority of abortions continue to be conducted by untrained personnel or induced by pregnant women themselves. On top of this, most women and girls face structural and informal hindrances barring them from safe services.The report urges decision-makers and health systems to improve accessibility, acceptability, quality and variety of contraception methods to reduce unwanted pregnancies by expanding <a href="https://www.nepalitimes.com/latest/sisterhoods-empowering-education-in-nepal/" target="_blank" rel="noopener noreferrer">sexual and reproductive health care </a>and public awareness. Equally crucial is to empower women and girls to make their own decisions in the matters of sex, contraception and motherhood.Says Baqui: “Contraceptives save lives and it is high time the Nepal government allocated the necessary financing to fulfil this fundamental human right."Read also: <a href="https://www.nepalitimes.com/?p=33648&amp;preview_nonce=5c7e9df60a&amp;preview=true" target="_blank" rel="noopener noreferrer">Born in Nepal</a>, Sewa Bhattarai<a href="https://www.nepalitimes.com/?p=33648&amp;preview_nonce=5c7e9df60a&amp;preview=true" target="_blank" rel="noopener noreferrer"> </a>

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1 in 2 pregnancies in Nepal unintended

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022111011114/636ccd339c7e80680e08bc62jpeg.jpg" alt="" width="1500" height="1627"/><figcaption>Photo: PRATIBHA TULADHAR</figcaption></figure>There is never a perfect time to have children because there is always something happening in your life. Either they are too young or too old, they are not financially stable enough or ready for the responsibilities or want to travel.No one else but the <a href="https://archive.nepalitimes.com/regular-columns/all-in-mind/the-choice-of-women-to-have-or-not-to-have-baby-should-be-respected,547" target="_blank" rel="noopener noreferrer">woman should decide when it is the right time</a> for her to have children. Sometimes, telling a woman that there is never a right time may end up in her having children at the wrong time, for the wrong reasons. Many of us know someone who decided to have a baby to save their marriage or due to societal pressure.“Women are born with a certain number of eggs and as women age, it is harder for women to conceive due to a decrease in the number considerably. Also, women may have a certain percentage of ‘abnormal’ eggs that when fertilised may result in miscarriages,” explains physician Sujan Rajbhandari Joshi. “It does become difficult for women to conceive after the age of 35, not saying that it is impossible or hopeless, but the probability of having a successful pregnancy is much higher at 25 or 30 compared to 35 or 40.”It is important to consider nature and biology when it comes to having children, although the magic of modern science has made many things possible. I know women who have had their first child at 40 and I know women who have been struggling to have children in their 20s— these experiences are subjective.Biologically speaking, a woman is physically healthy to bear children from her late teens to her early 20s. Fertility can also depend on age and genetics, so the sooner a woman can decide what she wants or does not want, the easier it is for her to work towards it.Preserving her fertility, or learning if she has any health issues such as polycystic ovarian syndrome, endometriosis or genetic history of reproductive issues, may affect her ability to get pregnant as discovered by many women. If you know you want children for sure but happen to be unsure when, it helps to know the best time to start <a href="https://archive.nepalitimes.com/article/nation/freezing-a-future-family-IVF-embryo-surrogacy,3881" target="_blank" rel="noopener noreferrer">freezing your eggs</a>.https://www.youtube.com/watch?v=kWqYSl-8tFQThere are ways of having children in the late 30s and 40s, but it may be more expensive and difficult because fertility treatments and <a href="https://archive.nepalitimes.com/article/nation/embryos-on-the-move,3162" target="_blank" rel="noopener noreferrer">In-Vitro Fertilisation</a> (IVF) may not always be successful. Another important factor is that if you have a male partner, his age will also affect his fertility and that may determine whether you can have kids.It is important to respect women’s privacy because some women may be trying to conceive without telling their family and friends, they may have suffered miscarriage or encountered unsuccessful IVF treatments. So telling them there is no right time, without even knowing what they have been through, would be cruel and hurtful. We can only plan and control so much about having a baby, the rest is up to chance.Also, it is important that you and your partner are on the same page about having and raising a baby, so you must consider if they want to be a parent too. The help and support of family do affect a woman’s ability to raise a child because affluent families have more resources to raise kids compared to someone from a low socioeconomic background.In Nepal, the pressure on women to have male children to continue to family lineage is just as great. Maya,32, is a successful working professional who has been married for five years. “I get pressure from my in-laws to have a child, preferably male. It makes me feel like everything I have done so far in life is inadequate. First it was the pressure to marry and now to have a child. Should I have a child for society if I have no desire to be a mother?” she questions.Are you willing to give up your spontaneous life of socialising to wake up in the middle of the night for a baby? Are you willing to give up the joys of being a mother to have a successful and happy career? There are sacrifices and losses on both sides and understanding what they entail would help a woman decide.If you did not want children for years and suddenly decide at 50 or 60 that you want to be a mother, you may be able to adopt a baby, but you must consider if it is in the best interest of the child. It is not enough to want to be a mother, but also important to be a good mother.Every decision related to having a baby has consequences. Factors, such as your age and fertility, financial stability, support of a partner, job, family, ambitions and how much are you willing to give up for what you want should be taken into account. This major decision can cause confusion and anxiety, and clash with other expectations.It is easy to allow society, parents, or your own biological clock to tell you that time is running out and feel guilt and shame for not wanting what a woman ‘should’ want. What other people say or what you read may influence your thoughts and views. But, you have to be honest with yourself, take the time to listen to your inner voice and do what you know is right for yourself.Anjana Rajbhandary writes this fortnightly Nepali Times column Life Time about socio-cultural issues, mental health and physical health.

Anjana Rajbhandary

Maybe baby

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221129151140/638619f69c7e80680e0cccd2jpeg.jpg" alt="" width="1500" height="844"/><figcaption>Photo: MARTY LOGAN</figcaption></figure>It should not be surprising that <a href="https://www.nepalitimes.com/latest/the-story-of-nepals-first-covid-19-fatality/" target="_blank" rel="noopener noreferrer">Nepal’s first COVID-19 death was a new mother</a>. What was surprising was to hear Prime Minister K P Oli admitting in Parliament on Tuesday that Nepal’s coronavirus deaths represented a failure of his government.<a style="font-size: 15px; letter-spacing: 0.01em;" href="https://www.nepalitimes.com/banner/3rd-month-of-lockdown/" target="_blank" rel="noopener noreferrer">Three Nepalis have died with coronavirus</a> since the pandemic hit Nepal. But that is the number of mothers who died every day across Nepal at childbirth. Despite dramatic strides in reducing the <a href="https://www.nepalitimes.com/here-now/who-will-save-nepals-poor-new-mothers/" target="_blank" rel="noopener noreferrer">maternal mortality</a> rate, 1,200 mothers still die while giving birth every year.Government statistics show that this number has risen dramatically in March and April, as women avoid hospitals because of the COVID-19 scare, as well as because of the lack of transport during the lockdown.The 29-year-old woman from Sindhupalchok, whose name has not been released, died on 16 May of post-partum sepsis and a <a href="https://www.nepalitimes.com/here-now/bhaktapurs-covid-19-heroes/" target="_blank" rel="noopener noreferrer">coronavirus infection</a> 10 days after safely delivering her baby at Teaching Hospital in Kathmandu, then returning home. There were delays in taking her to hospital after complications because the family could not find an ambulance.Even before the COVID-19 crisis, one of the reasons far too many Nepali women still give birth unsafely at home was the <a href="https://archive.nepalitimes.com/regular-columns/Comment/mothers-in-Nepal-still-dying-at-childbirth,1007" data-saferedirecturl="https://www.google.com/url?q=https://archive.nepalitimes.com/regular-columns/Comment/mothers-in-Nepal-still-dying-at-childbirth,1007&amp;source=gmail&amp;ust=1590230096851000&amp;usg=AFQjCNHGPAy4FgQc1EbtnlKIZJMxrFl6XA">high cost of ambulance</a> to take them to health facilities.Nepal has made <a href="http://archive.nepalitimes.com/article/nation/people-politics-placentas-child-delivery-complications,3922" target="_blank" rel="noopener noreferrer">progress in reducing maternal mortality</a> and <a href="https://www.nepalitimes.com/banner/born-in-nepal/" target="_blank" rel="noopener noreferrer">newborn deaths</a> thanks to the Safe Motherhood program, for which it received global recognition. But that improvement was nowhere enough to conclude that the job was done and the country could rest on its laurels.Figures show that in 1990, 901 women died per 100,000 births. That number was slashed to 239 per 100,000 live births in 2015. Yet the target for 2030 under the global Sustainable Development Goals is less than 70.If the health of pregnant women is still a government priority it has not been obvious during the lockdown. Pregnant women have been too fearful to visit clinics for crucial antenatal checkups, but by now arrangements should have been made for them to do so safely — or alternatives put in place — and those plans communicated to women.Of course, post-partum mothers are not the only Nepalis dying because of the broken health system. <a href="https://www.nepalitimes.com/here-now/kidney-patients-dying-due-to-covid-19-lockdown/" target="_blank" rel="noopener noreferrer">Non-communicable diseases </a> NCDs) are now the cause of most deaths in the country, led by heart disease, lung disease and stroke, but an NCD Multisectoral Action Plan spanning 2014-20 has yielded no visible results.The main causes of maternal mortality include post-partum bleeding, unsafe abortions, high blood pressure and post-delivery infection. Abortions aside — because there is still stigma attached to having one and a lack of knowledge about their legality — the other causes are treatable.Some initiatives have been taken. The President’s Women Uplift Program has used helicopters to rescue dozens of pregnant or post-partum mothers in emergency situations and many local governments have started programs to cajole or coerce women to give birth in facilities andto properly care for themselves and their newborns in the crucial days following delivery. But too many health facilities that should be providing services to pregnant women remain <a href="https://www.nepalitimes.com/here-now/who-will-save-nepals-poor-new-mothers/" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/here-now/who-will-save-nepals-poor-new-mothers/&amp;source=gmail&amp;ust=1590230096851000&amp;usg=AFQjCNEb9E7sQYw1XzmTTnMfGji3UmNybQ">under-staffed, ill-equipped and short of medicines</a>, and there is no visible national action plan, certainly no sense of urgency.Contrast media coverage of deaths of new mothers with those of women and girls practising chhaupadi in far western Nepal. Temporarily exiled from their homes during menstruation or after giving birth, they are at risk of snakebite, asphyxiation in tiny, windowless huts, and rape and physical assault. While outlawed, the practice continues.In recent years chhaupadi has been reported widely in Nepal and garnered numerous headlines in major global media. Yet, while roughly 15 women have died in <a href="https://www.nepalitimes.com/opinion/tipping-point-on-menstrual-banishment-in-nepal/" target="_blank" rel="noopener noreferrer">chhaupadi</a> in Nepal since 2010, there have been 15,000 women who died in that time from causes associated with giving birth. For much of the media, death during pregnancy has become too routine to deserve coverage.The prime minister was right to admit failure over the COVID-19 deaths to date: his government <a href="https://www.nepalitimes.com/latest/has-nepals-lockdown-just-postponed-covid-19/" target="_blank" rel="noopener noreferrer">has had ample time to craft a much more effective response, and has not</a>  The deficits in the health system overall have been evident, and discussed, throughout the decades that the prime minister and his colleagues in all parties have been in power. That deserves an admission of failure, followed by corrective action.

3 Nepali mothers still die daily at childbirth

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/20221108141124/636a58c19c7e80680e054852jpeg.jpg" alt="" width="1400" height="933"/><figcaption>WELCOME TO THE WORLD: A child sleeps in a hammock while its parents work in a workshop making idols for the Dasain festival in Kupondol. Photo: GOPEN RAI</figcaption></figure>Giving birth is a life or death issue in Nepal. Even though the maternal mortality rate dropped from 1,000 per 100,000 live births 40 years ago to 239 today, inadequate birthing facilities is still a problem. But attention is now also shifting to preventing pregnancies.There is a big <a href="https://www.nepalitimes.com/banner/implant-service-providers-take-contraception-to-nepals-poor/">unmet need for contraceptives</a>: nearly a quarter of women surveyed nationwide in 2016 said they were not using birth control, even if they need it. Social stigma, patriarchy, ignorance and lack of access were reasons.Nepal’s contraceptive prevalence rate is 52%, but in remote Bajura it is only 34%. Although progress is being made, we are still a long way from the government’s target of raising the rate to 75% by 2030.Read also: <a href="https://www.nepalitimes.com/?p=33714&amp;preview_nonce=033aa12640&amp;preview=true" target="_blank" rel="noopener">Nepal far from hitting contraceptive target,</a> Sewa BhattaraiAs our reports in this edition from Bajura and Chitwan show, there are cultural hurdles. With <a style="background-color: #ffffff; letter-spacing: 0.01em;" href="https://www.nepalitimes.com/here-now/migrating-males-and-population-decline/" target="_blank" rel="noopener">husbands away working for long periods</a>, their wives are reluctant to use contraceptives because of what others will say. The result: women suffer unwanted pregnancies, <a style="background-color: #ffffff; letter-spacing: 0.01em;" href="https://archive.nepalitimes.com/article/Nepali-Times-Buzz/globe-rallies-to-aid-nepals-women,3841" target="_blank" rel="noopener">unsafe abortions</a> and ultimately struggle to take care of large families.Almost every woman who visited a hospital in Bajura on a busy day last month had the same story: their husbands were away and they did not use birth control. Some were suffering from botched abortions.More than 800 abortion cases were registered in Bajura last year. Just one hospital in Achham terminated more than 600 pregnancies in one year. Meanwhile, Nepal’s total fertility rate has dropped from 6 in 1960 to near-replacement level at 2.05 today, and the country’s population growth rate is also down from 2.5% in 1990 to 1.1% today. Surveys in Province 2 and Far-western Province have shown a clear correlation between unwanted pregnancies, child marriage and fertility in regions with entrenched patriarchy.Among Nepalis, 21% use injectable contraceptives, 10% are on pills, 10% use condoms, 8% have IUDs and only 3% have implants. Depo-Provera was among the most used injectables, but it was difficult to administer and painful. Now, the government, with donor support, is field-testing in Nawalpur and Sindhuli a lower-dose injectable called Sayana Press, which could make contraceptives more accessible to women.Interventions like these, the government hopes, will reduce unwanted pregnancies, thus preventing unsafe abortions and reducing the number of women who have to take care of larger families.<a href="https://archive.nepalitimes.com/regular-columns/Comment/mothers-in-Nepal-still-dying-at-childbirth,1007" target="_blank" rel="noopener">Complications during pregnancy or at childbirth</a> are the leading causes of death among girls aged 15-19 in low-income countries like Nepal. Unwanted pregnancies also hamper women’s education and economic independence, and impact their family life, fuelling an intergenerational cycle of poverty and poor health.Read also: <a style="background-color: #ffffff; letter-spacing: 0.01em;" href="https://www.nepalitimes.com/banner/implant-service-providers-take-contraception-to-nepals-poor/" target="_blank" rel="noopener">Implant service providers take contraception to Nepal's poor</a>, Rojita Adhikari