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Kathmandu: Maya Kohar (21) of Dhakadhai, Rohini Rural Municipality-3, Rupandehi, like every day, worked in the fields all day on October 8, 2024 (Ashoj 22, 2081 BS) and went to sleep. She started experiencing unbearable abdominal pain in the middle of the night. She was then taken to the health post and admitted. Around 2 a.m., she gave birth.

Maya delivered her baby 5 weeks earlier than the date given by the health workers, at 34 weeks and 6 days. Her baby also had a lower than normal weight (1 kg 800 grams) compared to the standard 2.5 kg. The World Health Organization defines low birth weight as less than 2 kg 500 grams (5.5 pounds).

Sixteen months prior, on May 25, 2022 (Jestha 11, 2079 BS), Maya gave birth to her first child at the time specified by the health workers and in a normal manner. She is concerned that her second child was born prematurely. She said, "I started experiencing abdominal pain earlier than the date given by the doctor. The baby was born that same day. I don't understand why it was born early."

Although there are no specific scientific studies on Maya's problem, it is found that the increasing heat worldwide is affecting pregnant women, which is impacting births. Studies have also shown that excessive heat affects fetal development and increases the risk of premature birth.

A report titled 'Extreme Heat, Pregnancy and Stillbirth: Expert Review' by researchers including Ana Bonell of the London School of Hygiene & Tropical Medicine in the UK has shown that rising temperatures are affecting pregnant women. This study found that heat increases the risk of stillbirths, neonatal mortality, and affects the baby before birth.

' A Systematic Review and Meta-Analysis of the Impact of Heat Exposure Risks on Maternal, Fetal, and Neonatal Health' published in Nature Medicine also states that the risk of premature birth increases by 4% with every one-degree Celsius rise in temperature. During heat waves, this can reach up to 26%, according to the study.

A study led by Dr. Louise Wida, a researcher at the Wal-yan Respiratory Research Centre at the South Australian University and Telethon Kids Institute, and Professor Matthew Flinders and Corey Bradus of Global Ecology at Flinders University, showed that exposure to extreme temperatures increases the risk of premature birth by an average of 60%. This study, which reviewed global research, claimed a concerning increase in premature birth rates.

The study 'Development, Validation and Reliability of Scales and Items for Heat Wave Risk Assessment of Pregnant Women' showed that increasing heat increases the risk of preterm birth, stillbirth and low birth weight.

Public health expert Sujina Maharjan, who was involved in the study, says, "Fluctuations in temperature can cause mental stress and release stress hormones, which can cause the membranes to rupture prematurely. This leads to premature birth. In such cases, low birth weight babies are born."

The United Nations Framework Convention on Climate Change (UNFCCC) has included such current and potential impacts on human health due to rising temperatures in the non-economic losses caused by climate change.

Dr. Bijay Lamsal, a gynecologist at Siddhartha Children and Women's (AMDA) Hospital in Butwal, says that the impact of heat on pregnant women is a subject that needs to be studied and that it has an indirect effect.

According to him, working women come to the hospital. They do not pay attention to hygiene while working in the heat, which causes vaginal infections and urinary tract infections. Dr. Bijay said that these infections are a cause of preterm birth.

Normally, babies are born at 40 weeks of pregnancy, or 280 days. In medical terms, birth before 37 weeks is called preterm birth.

According to the 'Profile on Prevention and Care of Preterm and Low Birth Weight Births,' 14% of infants in Nepal are born prematurely. Out of the 577,000 babies born annually, approximately 81,000 are born before 37 weeks. Among them, 4,100 babies are born even before 28 weeks.

The '47 Studies on Premature Birth and Low Birth Weight Associated with Environmental Risks' published in Oxford Academy states that more than 20 million low birth weight babies are born worldwide every year. According to the study, 95% of low birth weight births occur in developing countries. Demographic studies indicate that 18% of babies born in Nepal have low birth weight.

According to Dr. Kalpana Upadhyay Subedi, Chief Consultant at Paropakar Maternity and Women's Hospital in Thapathali, it is very difficult to save a baby born before 28 weeks.

According to her, it is also difficult to save a baby born between 28 and 32 weeks. A baby born between 32 and 36 weeks is premature. It is somewhat easier to save them. Babies born between 37 and 40 weeks are not as difficult to raise. Dr. Kalpana says, "The earlier the birth, the more problems there are."

According to the 'Extreme Heat, Pregnancy and Stillbirth: Expert Review' report, problems such as premature birth, low birth weight, and abnormal fetal development can be caused by excessive heat.

This problem is not limited to Nepal but is emerging as a crisis worldwide, as shown by the 'Systematic Review and Meta-Analysis of the Impact of Heat Exposure Risks on Maternal, Fetal, and Neonatal Health' published in Nature Medicine. This study shows that rising temperatures have increased other adverse outcomes such as stillbirths, congenital anomalies and obstetric complications.

Premature birth affects the development of the child. Also, as it is difficult to save them, the Sustainable Development Goal of reducing child and infant mortality is also affected, Dr. Kalpana explains.

While there has been significant improvement in maternal and infant mortality rates in Nepal, the neonatal mortality rate has remained stagnant since 2016, according to the Nepal Demographic and Health Survey.

According to this 2022 survey, 21 out of every 1,000 deliveries result in stillbirths. One out of every 30 live-born children does not reach their fifth birthday. This indicates that achieving Nepal's Sustainable Development Goal (SDG) target of reducing the neonatal mortality rate to 12 per 1,000 live births by 2030 will be difficult, according to gynecologists Dr. Swaraj Rajbhandari and Dr. Kalpana.

Dr. Kalpana says, "The government has introduced programs to address problems such as preterm birth and low birth weight. There is a special training package for providing services to neonates and preterm babies. Focused work is being done on this, but it is still difficult to reduce the rate from 21 to 12."

Climate change also affects nutrition

Maya, who gave birth five weeks before her due date, is a farmer. Having become a mother of two children within three years of marriage, she was never free from household chores and farming work.

She said that she worked in the field until the day of delivery and that she felt the heat was more intense that year. When asked if she experienced the heat more because she was pregnant, she said that it was not like that the previous time.

"This year, it was very difficult to bear the heat; it was so hot that I couldn't even stay at home, and it was even more suffocating in the field; I carried a bottle of water, but it didn't last for an hour," Maya said. According to her, she experienced a lot of body fatigue, thirst and lethargy.

Research conducted by Ana Bonell and others has shown that intense heat affects the thermoregulation system in pregnant women's bodies, increases blood flow by up to 50%, and makes it difficult to keep the body cool. The study also found that dehydration, increased blood pressure, and a decrease in oxygen supply to the fetus can occur.

Like Maya, Muskan Mallah (20 years old) of Mahadeva, Mayadevi Rural Municipality-2, Rupandehi, also gave birth at 33 weeks of pregnancy. Health workers had given her a delivery date of December 11, 2024 (Mangsir 26, 2081 BS). However, seven weeks early, on October 18, 2024 (Kartik 2, 2081 BS), she went into labor and gave birth to a lower-than-normal weight baby (2 kg).

Manisha Baduwal Khadka, an auxiliary nurse midwife at Kamhariya Birthing Center who assisted her during delivery, says, "It was my duty during Muskan's delivery. Her baby was born prematurely and was also underweight."

According to Manisha, Muskan's health condition was critical, so she was referred to Bhim Hospital in Bhairahawa. The baby was treated in the NICU at Bhim Hospital. However, the baby's health did not improve, and the baby died on October 20, 2024 (Kartik 4, 2081 BS).

"Why was my baby born before the scheduled time? When it was born, it only had the form of a human, it was so soft and wobbly when I held it," Muskan lamented. "Even though I'm a mother, my lap is empty."

Saraswati Kohar (25) of Komrahiya, Mayadevi-1, shares a similar plight. A mother of two daughters, she gave birth prematurely both times. The first time, she delivered at 30 weeks on June 16, 2020 (Ashad 2, 2077 BS). The second time, on November 11, 2024 (Kartik 26, 2081 BS), she delivered at 32 weeks and 2 days.

Both daughters were underweight due to their premature births. She said she is having a much harder time raising her younger daughter than her elder one. Saraswati says, "It's very difficult to even feed her."

Like Maya and Muskan, Saraswati is also a farmer. Not only are their educational, social and economic conditions similar, but the problems they experienced during pregnancy are also shared.

Their village is located in one of the hottest regions of Nepal. They make a living by cultivating vegetables in an area where rice, wheat and vegetables are produced. They ate their usual food (rice, vegetables and occasionally lentils) during pregnancy, just like they did at other times. "What are nutritious foods?" Maya said. "We don't get to eat when we're hungry."

According to the data from the health post in Kamhariya, Mayadevi Rural Municipality-3, Kapilvastu, out of 91 deliveries up to the month of Mangsir 2081, 13 babies were born with low birth weight. The health post does not keep data on preterm births.

At Siddhartha Children and Women's Hospital in Butwal, out of 2,307 deliveries in 2078/79, 818 (35.45%) babies were born with low birth weight. In 2079/80, out of 1,791 deliveries, 630 (35.17%) babies were born with low birth weight, and in 2080/81, out of 1,324 deliveries, 498 (37.61%) babies were born with low birth weight, according to the hospital's data.

Although there are no official statistics on preterm births at Mayadevi's health post, nurse Sangita Sharma stated that preterm births are occurring. According to her, if a critical condition is seen, it is referred to Bhim Hospital in Bhairahawa.

Auxiliary nurse midwife Manisha says that she has not been able to find out the exact cause of preterm births. She says that one of the reasons for the birth of a low birth weight baby is premature birth.

According to Manisha, since many women are farmers, they work in the sun most of the time, and they do not eat enough nutritious food, which leads to the birth of low birth weight babies.

According to Nepal's census 2078, 68% of women are farmers. Among farmer families, only 44% are aware of climate change. Of those, 91% of farmer families said that climate change has affected agriculture. Among them, 85% reported a decrease in production.

Dr. Kalpana Upadhyay Subedi, Chief Consultant at Paropakar Maternity and Women's Hospital in Thapathali, stated that the decline in food production due to climate change is impacting nutrition.

The changed environment

A 2017 study published by the Department of Hydrology and Meteorology showed that Nepal's temperature is increasing by 0.056 degrees Celsius annually.

In some areas of Kapilvastu, Rupandehi, Nawalparasi-West, Chitwan, Parsa, Bara, Sarlahi, Dhanusha, Mahottari and Siraha districts, temperatures exceed 42 degrees Celsius.

From mid-April, most parts of the Terai region experience mild to severe heat waves. In 2023, maximum temperatures set new records in some places.

A study by Oxford Policy Management on climate change and disaster risk and vulnerability also showed that the annual minimum and maximum temperatures in the districts of Lumbini Province are increasing. The study, based on climate trend and scenario analysis, predicts an increase in extreme events of hot days and warm nights, with further increases expected in the future.

Rupandehi, Kapilvastu, Banke and Bardiya are at high risk of heat. The study includes that the increasing temperature trend leads to heat waves and heat waves pose a significant threat to healthy living.

The study has shown that there is an unequal impact on senior citizens, children, pregnant women, and poor and marginalized people.

The effects of heat during pregnancy

An article published in 'The Guardian' states that pregnant women, whose bodies carry a developing fetus, are at high risk of heat stroke as physical fatigue and hormonal changes during pregnancy affect thermoregulation.

The fetus, amniotic fluid (a clear or slightly yellow fluid that surrounds and protects the developing fetus in the uterus), and the placenta (a temporary organ that connects the mother's uterus to her developing baby through the umbilical cord) are all present. And, they are generating heat.

Extreme heat causes fatigue and dehydration, which triggers hormones involved in uterine contractions. If other problems accumulate, this can lead to labor and increase the risk of premature birth, low birth weight and stillbirth.

To maintain blood flow to the placenta and fetus, a pregnant person's blood volume increases by approximately 40% to 50% during pregnancy. Given the increased blood volume, amniotic fluid and other physical changes, pregnant women need to consume plenty of fluids to support fetal growth and prevent dehydration.

The 'Study of the Impact of Extreme Heat Exposure on Pregnant Women and Newborns' has shown that impaired fetal growth during pregnancy is associated with high temperatures.

High heat during pregnancy can contribute to fetal oxidative stress (a condition in which an imbalance of free radicals and antioxidants in the body damages cells and tissues) and inflammation. This can affect fetal growth and ultimately lead to low birth weight.

'A Study of the Relationship between Temperature and Preterm Birth Weight in Latin America' has shown that high heat exposure during pregnancy is associated with low birth weight.

A study by the 'Centers for Disease Control and Prevention' has shown that pregnant workers, in particular, are more susceptible to the risks of excessive heat exposure. According to the study, pregnant individuals are more likely to experience heat fatigue and heat stroke.

The 'Study Related to Risk Perception and Care Adaptation of Heat Wave in Nepalese Pregnant Women' shows that when the body's ability to regulate temperature decreases in heat, pregnant women are more at risk of heat stress than normal people.

The study showed a relationship between long and short-term heat exposure during pregnancy and an increased risk of severe maternal mortality.

The study was conducted using the Health Belief Model (HBM), a theoretical framework used to predict health behaviors. It researched to identify heat risks to pregnant women and related prevention and mitigation strategies, and the barriers to adopting such behaviors.

Most respondents participating in the study mentioned feeling high risk during heat waves. Pregnant women reported risks such as dehydration, increased body temperature, body weakness and sunburn. These are known physical challenges faced by pregnant women, which reduce thermoregulation capabilities.

The study found the severity of heat to be high. It showed that many women experienced heat-related conditions that could lead to serious health consequences, including hospitalization.

Problems in treatment

The World Health Organization has stated that climate change poses a threat to pregnant women, newborns and children due to various physical, clinical, social and behavioral factors.

The 'Call to Action: Protecting Maternal, Newborn, and Child Health from the Impacts of Climate Change' study states that climate change is a growing threat to maternal, newborn and child health, and should not be ignored. The study emphasizes the need to protect past progress in maternal, newborn, and child life and well-being.

At 37 weeks, all systems of the fetal physical structure are developed. The earlier a baby is born before 37 weeks, the less developed their physical structure is. Therefore, problems arise such as breathing difficulties due to poorly developed lungs, heart failure, difficulty following orders due to underdeveloped brains, and digestive problems due to poorly developed intestines. Every system is underdeveloped, making it difficult to adjust to the external environment.

In Nepal, some programs are underway to prevent premature births and neonatal mortality. Dr. Gauri Pradhan Shrestha, a gynecologist at the Family Welfare Division, informed that there are 61 Special Newborn Care Units (SNCUs) in government hospitals to treat infants with complications from premature birth.

However, according to gynecologist Dr. Swaraj Rajbhandari, district hospitals do not have pre-mature units. There are also not enough pre-mature units and NICUs in medical colleges and hospitals. Therefore, it is difficult to save neonates (newborns).

"The window period for a neonate is 1 hour. If they cannot be placed in the NICU within that time, it is difficult for our country," says Dr. Swaraj. "We have a shortage of neonatologists. We lack other resources. Therefore, we are taking this as a challenge."

She also states that there are not enough NICUs in Kathmandu. According to Dr. Swaraj, Thapathali Maternity and Women's Hospital has a 35-bed NICU (including a 10-bed ventilator-equipped NICU).

More studies needed to formulate policy

Issues related to the impact of heat on pregnant women worldwide have started to come under discussion. However, sufficient studies and research on this are still lacking. A study conducted by Ana Bonell and others emphasized that more research is needed on the relationship between excessive heat and pregnancy.

In Nepal, discussions and deliberations on this issue have also gradually begun. Dr. Kritipal Subedi, a gynecologist at Bheri Hospital, says that pregnant women are experiencing indirect effects due to environmental impacts. He points out the need for detailed studies to ascertain whether there are direct effects.

Dr. Gauri from the Family Welfare Division says that preterm births are happening in Nepal, but it is not possible to definitively say that this is due to environmental impacts. She says, "There has been no study on the issue of environmental impact; we also do not have the resources to conduct a study."

Although the issue of environmental changes affecting pregnant women is being raised worldwide, there are no studies or policies on this in Nepal. Organizations such as the World Health Organization and UNICEF are making efforts to find adaptation strategies to protect women and children from extreme heat in Africa, Latin America, and some countries in South Asia.

With the support of UNICEF, the Directorate General of Health Services (DGHS) in Bangladesh has developed national guidelines on heat-related illnesses to protect children and pregnant women from heat-related health risks.

The guidelines include topics such as being aware of heat stress, keeping oneself safe, identifying the symptoms of heat stress, making efforts to protect oneself and others, and taking a person to a health center if they experience severe symptoms.

The study emphasizes the need for a multi-sectoral approach that links health system strengthening, urban planning, social security, and climate change mitigation to address increasing climate-related risks and protect maternal health. It shows that there is a need to improve public health communication, improve health service system preparedness, and address practical obstacles such as water and electricity shortages.

It states that these initiatives, especially if focused on rural and socio-economically disadvantaged women, can mitigate the adverse effects of heat waves on both maternal and fetal health.

This story was produced under the NIMJN-CANSA Fellowship Program. Please adhere to our republishing policy if you'd like to republish this story. You can find the guidelines here.