Given the importance of the Nepali Patro, as part of the nation’s ‘sanskriti’ and ‘parampara,’ it is unlikely to be shifted to more exclusively ceremonia

In his presence and the sincerity of his voice, we felt deep respect and weighty importance that Dr. Ram Chandra Gautam placed on the Nepali Patro. He has been the chairman of the Panchanga Committee for the past three years, and a member for more than thirty. ‘Panch’ ‘anga’ literally means five limbs, and represents the elements of Nepal’s astrological calendar, the Nepali Patro or Bikram Samvat. Pandits spend several months a year studying the positions of the sun, constellations, and changing moon to lay out the calendar for the coming year with holidays, auspicious days, and events for almost every community of Nepal.

Many of Nepal’s diverse communities rely on the Nepali Patro to correctly carry out religious activities and plan important events, like weddings. Unlike the Gregorian calendar, these dates change with each year’s new calendar, just as the stars and planets are continuously in motion. But not only do these dates change, the number of days in each month varies. Nepal’s businesses, policy-makers, and academic institutions need to adjust to the unpredictable dates of the years ahead. This is a cost for Nepal in a globalized society and economy that almost universally uses the Gregorian calendar. Yet the government views these as small administrative nuisances in comparison to the generations of culture and national pride manifested in the Nepali Patro.

There is one place that we have found where this balance places mothers and their newborns at risk of poor care and poor outcomes. In our work with Nyaya Health Nepal, a healthcare organization that partners with the Ministry of Health in delivering high quality free services in rural areas, we work with midwives and community health workers on strengthening maternal and child healthcare. As we developed an enhanced antenatal care program, we found that mid-level practitioners responsible for basic antenatal care calculated Gestational Age (GA) by counting months from a woman’s last menstrual period. A human gestation is defined as nine months and seven days after the last menstrual period. So this method of calculation seems quite reasonable.

As we move from the Millennium Development Goals to the Sustainable Development Goals, with an increased focus on improving newborn survival and reducing stillbirths with continued efforts to reduce maternal mortality there are several interventions that require precise GA measurement. Imprecise measurement could lead to a delay in induction of labor in a pre-eclamptic, for example, and thus an increased risk of seizures in a mother and stillbirth. Pre-eclampsia affects about 10% of pregnancies. A woman in preterm labor should receive steroids to prevent respiratory distress of her preterm newborn and magnesium to prevent cerebral palsy. These medications could introduce increased harm to the neonate if the labor is not preterm prior to 34 and 32 weeks, as a large multi-country study recently suggested. Techniques for safe abortion require that GA be determined as less than 9 or 12 weeks.

A simple low-tech tool, the pregnancy wheel, was created for GA calculation using the Gregorian calendar. Two concentric circles marked with calendar dates and weeks of pregnancy slide against one another to determine delivery date and GA. This tool is in wide use in most parts of the world. The WHO is developing a new version of the wheel that incorporates guidance on intervention by GA week. These wheels cannot accommodate an ever-changing Nepali Patro. Without such a tool, midwives and care providers throughout Nepal have a choice to either count by months or laboriously count by weeks on the calendar. From our experience, almost no providers have the time to count out GA by weeks. When counting by months, GA dating can lead to inaccuracies of as much as two weeks.

Government antenatal cards do require providers to document GA by week at each visit. To address this issue, some providers report using a short cut of considering each month as four weeks. This becomes more inaccurate as the gestation advances because all months are truly longer than four weeks. Some report a correction factor of adding an extra week per trimester. This works if a woman presents precisely at the end of each trimester. But for those who present between trimesters with a symptom, the dating is again imprecise.

As part of our care-delivery model, we are developing a robust integrated Electronic Health Record (EHR) system. This system is capable of computing GA using just a woman’s date of last menstrual period. The care provider enters the Nepali Patro date; it is converted into the Gregorian calendar date, and put into a formula to get the GA in weeks based on the Gregorian date that the woman presents on. Once our system is fully implemented, health post staff using computers as well as community health workers using mobile phones will be able to use this tool. Working towards a national EHR is certainly a goal of the Nepal government. But should rural women and their children be subject to missed opportunities for high quality care in the meantime? Given the importance of the Nepali Patro, as part of the nation’s ‘sanskriti’ and ‘parampara,’ it is unlikely to be shifted to more exclusively ceremonial, rather than governance, functions, any time soon. It is imperative we accelerate technology and develop simple tools within this system to improve the safety of high-risk pre­­­gnancy as we make critical treatments accessible to all.