Unstable health policy is killing Nepal's infants

Maya Devi's face is contorted with pain as she lies inside a roadside inn near the Bajhang village in the mountains of Nepal's remote western region. For the past six days she has been in labour.

The nearest health clinic is six hours away across a rough mountain road, but rains had blocked it. Without medical attention, Maya Devi's helpless relatives had given up hope of either mother or baby surviving.

Later that night, Maya Devi delivered a still born baby boy with bluish skin - the baby had been strangled by his own umbilical cord.

Maya Devi was lucky to have survived. Every year, 520 out of every 100,000 Nepali women die at childbirth - making the landlocked Himalayan nation's maternal mortality rate, one of the highest in South Asia.

Even by Nepal's abysmally low health standards, the conditions in the hilly, road-less districts of western Nepal are much worse than the national average. Of every 1,000 children born in Nepal, about 118 die before their fifth birthday, but in western Nepal one in every five babies dies in the first year of life.

Early marriage, high fertility rates, inadequate health care, widespread undernourishment and ingrained cultural bias against women are some of the reasons. Ignorance and superstition also play a part in the high death rate of Nepali mothers.

''Women are bound by tradition to deliver their babies in cowsheds, often without the support of birth attendants. No amount of coaxing will make them change their minds,'' says Brinda Kunwar, a health worker based in the mountain town of Jumla which is so remote that the only way to reach it is by foot or helicopter.

According to UNICEF, Nepal has one of the worst statistics on child survival in South Asia. Only war-ravaged Afghanistan and Bhutan are worse off.

UNICEF would like South Asian countries to follow the role model of Sri Lanka in child and mother care. The island nation has shown how investment in basic health and education yields dividends: the country's maternal mortality rate is 80 per 100,000 births.

While only 6 per cent of Nepali women are attended by trained health personnel during delivery, in Sri Lanka the figure is 94 per cent. Despite a costly civil war, Sri Lanka still spends 40 per cent of its budget on health and education. In Nepal the figure is only 15 per cent.

''We keep on telling the planners that it is not adequate, but even what we have is not used effectively,'' says Ramesh Kanta Adhikari, professor of pediatrics in Nepal's Institute of Medicine. Managerial and administrative inefficiency, frequent changes in the government's health ministry because of political instability have seriously affected health delivery, he adds.

Nepal's under-five mortality rate has gone down, mainly because of the success in anti-dehydration and vaccination campaigns. But a stagnant economy and persisting inequities have meant that a large proportion of the population is underfed.

Though it is poorer, only 32 per cent of the children in sub-Saharan Africa are underfed - much lower than the 51 per cent of South Asian under-fives that suffer from chronic malnutrition, according to UNICEF's progress of nations report launched earlier this year.

UNICEF says it is not sure why this is the case, but says all signs point to the low status of women not only in society but also within the family, which means that mothers have to give more attention to their husbands and in-laws than their own babies.

Adhikari explains: ''Unlike immunisation and oral rehydration, nutrition programmes require the involvement of mothers, breast-feeding, food prices, maternal nutrition. It is very complex.''

Though breast-feeding is almost universal in South Asia, low nutrition level of mothers and the influence of commercial baby food formulas - especially in Bangladesh and Pakistan - have affected this valuable source of nourishment for babies.

While governments in the region are committed to popularising breastfeeding, only Sri Lanka is vigorously pursuing the campaign to make hospitals baby-friendly. A 10-year campaign was kicked off by former chief of the UNICEF James Grant in the island nation's oldest maternity hospital in 1992.

The campaign initiated by UNICEF in collaboration with the World Health Organisation had by July 1995 managed to convert 37 hospitals countrywide and 10 maternity units in the capital city into ''baby-friendly'' institutions. With 90 per cent of Sri Lankan women delivering in institutions, the message that breastfeeding is safe, hygienic and inexpensive has spread.

But in the rest of South Asia the situation is bleak.

If present trends are any indication, 3.5 million under-fives will still be dying from poverty-related causes at the dawn of the next century and millennium. A quarter of the world's children live in South Asia, and their numbers swell by 37 million every year.

UNI