a b s t r a c t a r t i c l e i n f o Keywords:Community-based distribution Misoprostol Nepal Operations research Postpartum hemorrhage Self-administration Objective: To determine feasibility of community-based distribution of misoprostol for preventing postpartum hemorrhage (PPH) to pregnant woman through community volunteers working under government health services. Methods: Implemented in one district in Nepal. The primary measure of performance was uterotonic protection after childbirth, measured using pre-and postintervention surveys (28 clusters, each with 30 households). Maternal deaths were ascertained through systematic health facility and community-based surveillance; causes of death were assigned based on verbal autopsy. Results: Of 840 postintervention survey respondents, 73.2% received misoprostol. The standardized proportion of vaginal deliveries protected by a uterotonic rose from 11.6% to 74.2%. Those experiencing the largest gains were the poor, the illiterate, and those living in remote areas. Conclusion: Community-based distribution of misoprostol for PPH prevention can be successfully implemented under government health services in a low-resource, geographically challenging setting, resulting in much increased population-level protection against PPH, with particularly large gains among the disadvantaged.

Retrospective study of 6 cases of puerperal inversion of the uterus is being presented from 1975 to 1995 and a review of literature for 20 years of the period 1975-1995 has been summarised. In the present series, one case with acute puerperal inversion of uterus were treated by manual reposition, 2 cases of chronic puerperal inversion of uterus was treated surgically by Kustner's vaginal approach. Two cases with subacute puerperal inversion of uterus, 1 case of chronic puerperal inversion were treated by Haultain and Huntington method. Out of 241 cases of uterine inversion obtained from review of literature for last 20 years, 229 (95%) constituted puerperal and 12 (5%) were non puerperal inversions. Among puerperal inversions, 191 (83.4%) cases were of acute type and only 6 (2.62%) cases were of subacute variety. The chronic puerperal inversion constituted 32 (13.9%). Out of 63 cases of uterine inversions in India, maternal deaths were reported as 6 (9.5%) but there was no maternal death in the present series.

Introduction: Menopause is an unavoidable and sometimes problematic condition in which women may suffer from a number of health problems. Knowledge of the major symptoms associated with menopause helps reduce the burden and stress associated with the condition. In this context, a study was conducted to establish baseline data regarding menopausal health problems among Nepalese women. Methods: A descriptive cross-sectional study was conducted among 2000 women aged over 40 years to identify their knowledge, attitude and practice related to menopausal health problems. Data was collected by interviewing the women and doing physical examination. Analysis was done using descriptive statistics and SPSS software was used for data analysis. Results: A cohort of 2073 women (ages 40-60 years) participated in the research, among them 2000 yielded complete response. The study revealed that 820 (41%) women had reached menopause. The average age of menopause was 48.7 years. Majority of the women 1183 (59.2%) in the study did not know about menopausal health problems. Abnormal bleeding 353 (17.65%), sweating 315 (15.75%), hot flushes 299 (14.95%), joint/muscle pain 285 (14.25%) were the most common menopausal symptoms known by the women. Joint pain 736 (36.8%), hot flushes 584 (29.2%), irregular bleeding 582 (29.1%) were the most common experienced symptoms of menopause and only 586 (29.3%) consulted the health workers to alleviate menopausal symptoms. Moreover, most of the women 926 (46.3%) accepted menopause as a part of life. Conclusions: The research has tried to establish the baseline of menopausal health problems in the Nepalese women. The average age of menopause was 48.7 years. Majority did not know about menopausal health problems. Further researches with nationally representative sample are recommended to further explore the menopausal health problems of Nepalese women.Keywords: health problems; menopause; Nepal; women.

BackgroundIn 2009, the Nepal Ministry of Health and Population launched a national program for prevention of postpartum hemorrhage (PPH) during home births that features advance distribution of misoprostol to pregnant women. In the years since, the government has scaled-up the program throughout much of the country. This paper presents findings from the first large-scale assessment of the effectiveness of the advance distribution program.MethodsData collection was carried out in nine districts and all three ecological zones. To assess knowledge, receipt and use of misoprostol, household interviews were conducted with 2070 women who had given birth within the past 12 months. To assess supply and provision of misoprostol, interviews were conducted with 270 Female Community Health Volunteers (FCHVs) and staff at 99 health facilities.ResultsAmong recently delivered women, only 15% received information about misoprostol and 13% received misoprostol tablets in advance of delivery. Yet 87% who received advance misoprostol and delivered at home used it for PPH prevention. Among FCHVs, 96% were providing advance misoprostol for PPH prevention; however 81% had experienced at least one misoprostol stock out within the past year. About one-half of FCHVs were providing incomplete information about the use of misoprostol; in addition, many did not discuss side effects, how to recognize PPH or where to go if PPH occurs. Among health facilities, just one-half had sufficient misoprostol stock, while 95% had sufficient oxytocin stock, at the time of this assessment.ConclusionsIn Nepal, women who receive advance misoprostol are both willing and able to use the medication for PPH prevention during home births. However the supply and personnel challenges identified raise questions about scalability and impact of the program over the long-term. Further assessment is needed.

This case study utilizes the four domains of effective Networks of Care (NOC) as a lens to describe the suite of interventions of a biosocial approach to maternal and neonatal health services in rural Nepal: The Network of Safety model, created by the non-governmental organization One Heart Worldwide (OHW) in collaboration with the government health system in Nepal. This approach provides essential guidance in the areas of health financing, governance, sustainability, reflection of user preference, and scalability. OHW addresses the reproductive health needs of women living in remote areas of Nepal in collaboration with local-level health and government workers by emphasizing clinical skill development and mentorship in management and leadership. With Nepal's shift to Federalism, the OHW approach proved flexible and able to deepen its support to leaders in new local-level government structures. The results on the ground were remarkable: using analytic skills gained from their OHW partnership, municipality leaders and health workers demonstrated effective communication and proactive responses to challenges, while maintaining fidelity to the Network of Safety model. The six-year commitment made by OHW to partner municipalities promoted active learning and adaptation and is a clear contributor to the scalability of the OHW Network of Safety. Observing the Network of Safety work through the domains of NOC highlights the interdisciplinary effort required to successfully transform Maternal and Neonatal Health (MNH) services in rural Nepal.

Background: We describe an on-site clinical mentoring program aimed at improving emergency obstetrical and newborn care (EmONC) in Nepal and assess its effectiveness on nurses' knowledge and skills. In Nepal, both the maternal mortality ratio (MMR, 239/100,000 live births) and the neonatal mortality rate (NMR, 21/1000 live births) were among the highest in the world in 2016, despite impressive progress over recent decades considering the challenging environment. Methods: From September 2016 to April 2018, three experienced nurses conducted repeated mentoring visits in 61 comprehensive or basic EmONC centers and birthing centers located in 4 provinces of Nepal. Using updated national training manuals and teaching aids, these clinical mentors assessed and taught 12 core EmONC clinical skills to their nurse-mentees. Clinical mentors worked with management mentors whose goal was to improve the nurses' working environment. We assessed whether the cohort of nurse-mentees performed better as a group and individually performed better at the end of the program than at baseline using relevant tests (chi-square test, Wilcoxon matched-pairs signed-rank test, and Kruskal-Wallis equality-of-population rank test). Results: In total, 308 nurses were assessed, including 96 (31.2%), 77 (25.0%) and 135 (43.8%) who participated in all three, two or only one mentoring session, respectively. In total, 225 (73.0%) worked as auxiliary nurse-midwives (ANMs), while 69 (22.4%) worked as nurses. One hundred and ninety five (63.3%) were trained as skilled birth attendants, of which 45 (23.1%) were nurses, 141 (72.3%) were auxiliaries and 9 (4.6%) had other positions. The proportion of ANMs and nurse-mentees who obtained a knowledge assessment score ≥ 85% increased from 57.8 to 86.1% (p < 0.001). Clinical assessment scores increased significantly for each participant, and therefore for the group. SBA-trained mentees had better knowledge of maternal and newborn care and were better able to perform the 12 core clinical skills throughout the program. Conclusions: Our study suggests that on-site clinical mentoring of nurses coupled with health facility management mentoring can improve nurses' clinical competences in and performance of maternity and newborn care. Assessing evidence of impact on patient safety would be the next stage in evaluating this promising intervention.

A cross-sectional study was conducted among women of different ethnic groups aged 40 to 60 years and health workers in different parts of Nepal using focus group discussions (FGDs), key informant interviews (KIIs) and clinical examinations to determine the symptoms and complains related to menopause. The mean age at menarche was 15 years and the mean age of menopause was 47. The highest menarche and menopause (50 years) was found to be among the Gurung women. Mean age of menopause was found to be higher among currently older women (52 years among 60+ women vs 41 years among <45 years women) and unmarried women. Tharu perimenopausal women and Sarki, Gurung and Tharu postmenopausal women were found to have relatively more regular menstrual cycles. However, Tharu perimenopausal women were found to have excess bleedings during the menstrual cycle. Most of the women had heard about menopause but did not have detailed knowledge on it. Loss of sexual interest (95.3%), decreased visual activity (58%), joint pain (31.3%) and body pain (31.3%) were the most commonly reported menopausal symptoms. Mean body mass index (BMI) was highest among the Gurung women (both perimenopausal and postmenopausal). Pap smear was normal in all 138 women but around 50% had some cervical and vaginal-related problems. One-third of Tharu postmenopausal women had atropic labia and onethird of Tamang women had leukoderma. Since, very little knowledge is known about the postmenopausal symptoms and problems in Nepal, this study can serve as the basis for further researches in this area with an increased sample size. How to cite this article Rajbhandari S, Amatya A, Giri K. Relation of Ethnicity and Menopausal Symptoms in Nepal. J South Asian Feder Menopause Soc 2013;1(2):50-55.

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