Auxiliary Nurse Midwife (ANM) in Nepal: Past, Present, and Future

Introduction

The health system of Nepal has gone through massive transformations over the past few decades. One of the pivotal roles in improving healthcare delivery, especially in rural and underserved areas, has been played by Auxiliary Nurse Midwives (ANMs). These healthcare workers serve as the first point of contact for maternal and child health services in many parts of the country.

In this blog, we explore the past, present, and future of the ANM profession in Nepal and provide insights into courses and colleges that offer ANM programs.

The Past: Laying the Foundation

The Auxiliary Nurse Midwife profession in Nepal dates back to the 1960s and 70s, when maternal and child health (MCH) became a national priority. At that time:

• Nepal faced alarming rates of maternal and infant mortality.

• Health services were extremely limited in remote areas.

• The government, with support from international agencies, launched training programs to create a workforce of mid-level health professionals who could deliver basic services.

ANMs were primarily trained to:

• Conduct safe deliveries.

• Provide antenatal and postnatal care.

• Treat minor ailments.

• Offer family planning and immunization services.

These professionals were crucial, especially because doctors and nurses were rare in rural villages.

The Present: Expanding Roles and Responsibilities

Today, ANMs in Nepal are a cornerstone of the community health system. Their responsibilities have expanded significantly, including:

• Maternal, neonatal, and child health care.

• Family planning services and counseling.

• Immunization programs (especially EPI – Expanded Programme on Immunization).

• Nutrition education and health promotion.

• Basic emergency obstetric care in primary health care centers.

• Disease surveillance and health reporting at the community level.

• Community outreach and home visits.

ANMs now work in:

• Health Posts

• Primary Health Care Centers

• NGOs and INGOs

• Community Health Clinics

• Hospitals (in supportive roles)

The government’s National Health Policy recognizes ANMs as key players in achieving Universal Health Coverage (UHC) and Sustainable Development Goals (SDGs).

The Future: Challenges and Opportunities

The future of ANMs in Nepal looks promising, but it comes with challenges:

Opportunities:

• Advanced Training Programs: Upgrading from ANM to Staff Nurse (PCL Nursing) or Bachelor’s level nursing education.

• Greater Scope: Involvement in mental health, elderly care, and non-communicable diseases.

• Leadership Roles: Some ANMs are being trained to manage health posts.

• Digital Health Tools: Use of mobile apps and telemedicine to reach even more remote populations.

Challenges:

• Retention: Many trained ANMs leave rural postings due to lack of incentives and poor working conditions.

• Skill Gap: New diseases and health conditions require continuous training.

• Recognition: Many ANMs still struggle to get recognition for their work compared to higher-level health professionals.

With investments in capacity building, infrastructure, and professional development, ANMs can continue to be the backbone of Nepal’s healthcare system.

ANM Course Overview in Nepal

Program Name: Auxiliary Nurse Midwife (ANM)
Duration: 18 months (approximately)
Eligibility: SEE/SLC passed with minimum GPA as per CTEVT standards.
Curriculum Includes:

• Basic Nursing Care

• Midwifery and Obstetrics

• Child Health Nursing

• Public Health and Community Health Nursing

• First Aid and Emergency Care

• Family Planning and Counseling

• Health Education

Accreditation: Most ANM courses are affiliated with CTEVT (Council for Technical Education and Vocational Training).

After completing ANM, graduates can also pursue Staff Nurse (PCL Nursing), a bridge course, or Bachelor in Nursing Science (BNS) after gaining work experience.

Colleges Offering ANM Courses in Nepal

Here are some notable institutes offering ANM courses:

Apart from these, many technical schools and community colleges across all provinces offer the ANM program to increase local accessibility.

Conclusion

Auxiliary Nurse Midwives have been — and will continue to be — vital in shaping Nepal’s public health system. From delivering babies in remote villages to helping fight national health emergencies, their contribution is immense.

With evolving healthcare needs, ANMs are expected to take on broader and more specialized roles. Supporting their education, career advancement, and working conditions is not just an investment in their future, but in the health of Nepal itself.

🚨 Erythema Migrans: The Early Sign of Lyme Disease! 🚨

Erythema migrans (EM) is the hallmark early sign of Lyme disease, a tick-borne illness caused by the bacterium Borrelia burgdorferi. Recognizing this distinctive rash is crucial for timely diagnosis and treatment, preventing the progression to more severe stages of the disease. (Lyme Disease: Symptoms, Treatment, Prevention & Recovery)

🦠 Cause: Borrelia burgdorferi (Tick-Borne)

Lyme disease is transmitted to humans through the bite of infected black-legged ticks, commonly known as deer ticks. These ticks are prevalent in wooded and grassy areas, particularly in the northeastern and north-central regions of the United States. The bacterium Borrelia burgdorferi resides in the tick’s gut and is transferred to humans during feeding. (What You Need to Know About the Stages of Lyme Disease)

🔴 Appearance: The “Bull’s-Eye” Rash

Erythema migrans typically manifests as a red, expanding rash that often exhibits central clearing, giving it a characteristic “bull’s-eye” or target-like appearance. However, the rash can vary in presentation: (Lyme disease. Borrelia burgdorferi infection – DermNet)

• Classic Bull’s-Eye: A red outer ring with central clearing.

• Uniformly Red Lesion: A solid red patch without central clearing.

• Multiple Lesions: In some cases, multiple EM rashes may appear, indicating disseminated infection.

The rash is usually not itchy or painful but may feel warm to the touch. It commonly appears at the site of the tick bite. (Lyme disease, [PDF] The Many Forms of Lyme Disease Rashes (Erythema Migrans) | CDC)

lyme disease bulls eye rash (source: bbc)

⏳ Timing: Appears 7–14 Days After a Tick Bite

Erythema migrans typically develops between 7 to 14 days after a tick bite, though the onset can range from 3 to 30 days. The rash expands gradually over several days and can reach up to 12 inches (30 cm) or more in diameter. Early recognition of EM is vital, as it allows for prompt treatment and reduces the risk of complications. ([PDF] The Many Forms of Lyme Disease Rashes (Erythema Migrans) | CDC, The Spectrum of Erythema Migrans in Early Lyme Disease)

⚕️ Treatment: Doxycycline or Amoxicillin

Early-stage Lyme disease, indicated by the presence of erythema migrans, is effectively treated with antibiotics. The choice of antibiotic depends on the patient’s age, pregnancy status, and other factors: (What You Need to Know About the Stages of Lyme Disease)

• Doxycycline: 100 mg twice daily for 10–21 days; not recommended for pregnant women or children under 8 years old.

• Amoxicillin: 500 mg three times daily for 14–21 days; suitable for pregnant women and young children.

Early treatment usually leads to a full recovery. Delays in treatment can result in the spread of the infection to joints, the heart, and the nervous system.

🧠 Additional Symptoms to Watch For

In addition to the rash, early Lyme disease may present with flu-like symptoms:

• Fever and chills

• Headache

• Fatigue

• Muscle and joint aches

• Swollen lymph nodes (Identifying Lyme Disease Rash From Pictures – Verywell Health)

If left untreated, the infection can progress to more severe stages, leading to complications such as arthritis, neurological disorders, and cardiac issues.

🛡️ Prevention Tips

Preventing tick bites is the most effective way to avoid Lyme disease: (Lyme disease)

• Wear long sleeves and pants when in wooded or grassy areas.

• Use insect repellents containing DEET on skin and permethrin on clothing.

• Perform thorough tick checks after outdoor activities.

• Shower soon after being outdoors to wash off unattached ticks.

• Promptly remove any attached ticks with fine-tipped tweezers.

📷 Visual Reference

For images illustrating the various presentations of erythema migrans, please refer to the Centers for Disease Control and Prevention (CDC) Lyme Disease Rashes page. These images provide valuable visual references to aid in the recognition of this early sign of Lyme disease. (Lyme Disease Rashes – CDC, The Spectrum of Erythema Migrans in Early Lyme Disease)

Early detection and treatment of erythema migrans are crucial in preventing the progression of Lyme disease. If you suspect a tick bite or notice a suspicious rash, consult a healthcare provider promptly.

Lek Lagnu: Understanding HAPE and HACE at High Altitudes

Lek Lagnu

Lek lagnu (लेक लाग्नु) is a common term in Nepali, referring to the life-threatening effects people can experience at high altitudes. While it can describe general altitude sickness, medically it often points to two severe conditions: High-Altitude Pulmonary Edema (HAPE) and High-Altitude Cerebral Edema (HACE). Both are emergencies that require immediate attention.

What is HAPE (High-Altitude Pulmonary Edema)?

HAPE is a condition where fluid collects in the lungs, making it extremely difficult to breathe. It usually occurs above 2,500 meters (8,200 feet), but it can happen at lower altitudes if a person ascends too quickly.

Symptoms of HAPE:

• Difficulty breathing, even while resting

• Severe coughing, sometimes with frothy or blood-tinged sputum

• Chest tightness or congestion

• Extreme fatigue and weakness

• Blue or gray lips and fingernails (due to lack of oxygen)

Why does HAPE happen?
At high altitudes, the lower oxygen pressure causes the blood vessels in the lungs to constrict. In some people, this leads to leakage of fluid into the air spaces of the lungs, making breathing almost impossible.

What is HACE (High-Altitude Cerebral Edema)?

HACE is even more serious and involves swelling of the brain due to lack of oxygen. It typically happens at altitudes above 3,000 meters (about 10,000 feet) but can occur lower if ascent is too rapid.

Symptoms of HACE:

• Severe headache that does not improve with painkillers

• Loss of coordination (walking unsteadily)

• Confusion, irritability, or hallucinations

• Drowsiness that can progress to unconsciousness

• Seizures in extreme cases

Why does HACE happen?
Reduced oxygen at high elevations causes brain blood vessels to leak fluid, leading to dangerous swelling inside the skull.

Key Differences between HAPE and HACE

How to Prevent Lek Lagnu (HAPE and HACE)

• Ascend slowly: No more than 300–500 meters per day once above 3,000 meters.

• Acclimatize properly: Rest every few days to adjust to the altitude.

• Stay hydrated: But avoid alcohol and sleeping pills.

• Recognize early symptoms: Never ignore headaches, breathing problems, or confusion at high altitude.

• Descend immediately: The best and fastest treatment for HAPE and HACE is to move to a lower altitude as quickly as possible.

• Oxygen and medication: Supplemental oxygen, and medicines like nifedipine (for HAPE) or dexamethasone (for HACE), can save lives if available.

Conclusion

Lek lagnu is not just a minor inconvenience; it can be deadly if it progresses to HAPE or HACE. Anyone trekking, climbing, or traveling to high-altitude areas like the Himalayas must be aware of the risks and take preventive measures seriously. Quick recognition, proper acclimatization, and immediate descent are the best defenses against these life-threatening conditions.

Medical Notes: Face to Pubis delivery : What are the risk factors for it?

Which type of pelvis is associated with an increased incidence of face-to-pubis delivery?

a. Gynecoid pelvis
b. Anthropoid pelvis ✅ (Correct Answer)
c. Android pelvis
d. Platypelloid pelvis

Answer: b. Anthropoid pelvis

Solution:

Face-to-pubis delivery is most commonly associated with the Anthropoid pelvis.

Types of Pelvis:

1. Gynecoid Pelvis

• Normal female pelvis

• Most common type

• Transverse diameter > Anteroposterior (AP) diameter

2. Anthropoid Pelvis

• AP diameter > Transverse diameter

• Face-to-pubis delivery is common

3. Android Pelvis

• Male-type or wedge-shaped pelvis

• All diameters reduced

• Delayed engagement

• Deep transverse arrest

4. Platypelloid Pelvis

• Flat pelvis type

• Transverse diameter > AP diameter

• Least common type

• Shortest diameter of pelvic inlet = Obstetric conjugate

Additional Important Points:

• Most important diameter during labor: Interspinal diameter (of the pelvic outlet)

• Shortest diameter of the fetal skull: Bimastoid diameter

• Largest diameter of the fetal skull: Mento-vertical diameter

Rheumatoid Arthritis

Pathological Change

• In Rheumatoid Arthritis (RA), the synovium becomes edematous (↑ fluid content, ↓ viscosity), leading to:

  • Thickening, then hypertrophy, and finally

  • Pannus formation — hallmark of disease involving fibroblasts and small blood vessels.

General Characteristics

• RA is a non-suppurative chronic disease.

• Symmetrical inflammation of peripheral joints with progressive destruction of periarticular structures.

• Associated with HLA Class II genes: HLA-DR, HLA-DQ.

Most Common Joints Affected

• MCP of index finger > Wrist > PIP > MTP > Knee, Ankle, Shoulder, Elbow.

• DIP joints spared (DIP joints are involved in Osteoarthritis, not RA).

Important Autoantibodies

• Most specific: Anti-CCP antibodies.

• Rheumatoid factor (RF): IgM antibodies directed against Fc portion of IgG.

Common Complications

• Tendon rupture: Extensor digitorum communis (most common).

• Eye complication: Dry eye (Sicca syndrome) — seen in ~38%.

• Lung complication: Interstitial Lung Disease (ILD).

Characteristic Deformities

• Z-deviation of hand:

  • Radial deviation at the wrist.

  • Ulnar deviation of fingers.

• Swan neck deformity: Hyperextension of PIP, flexion of DIP.

• Hill’s hiker’s thumb:

  • Extension at 1st IP joint.

  • Flexion at 1st MCP joint.

  • Loss of thumb mobility and pinch.

• Hammer toes.

X-ray Findings

• Juxta-articular osteopenia.

• Bone erosions.

• ↓ Joint space due to cartilage loss.

Syndromic Associations

• Felty’s syndrome: Chronic RA + Splenomegaly + Neutropenia (<1500 cells/mm³).

• Caplan’s syndrome: Pulmonary nodules + Pneumoconiosis in RA patients.

Treatment

• First-line (DOC): Methotrexate (DMARD).

• Best analgesic: Naproxen.

• Biologics:

  • TNF inhibitors: Etanercept, Infliximab, Adalimumab.

  • Rituximab (anti-CD20 monoclonal antibody).

MCQ

Q. Which structure in the joint is affected earliest in Rheumatoid Arthritis?

a. Capsule
b. Articular cartilage
c. Synovium ✅
d. Subchondral bone

Here’s a list of antiemetic medications that can be used for nausea and vomiting in pregnancy (NVP), typically in order of preference and safety:

First-line

Second-line

Third-line

Others (used cautiously or in severe cases)

CBIMNCI (CB IMNCI) protocol Nepal for Health professionals

CBIMNCI protocol has been one of the driving guideline for treatment of neonatal and childhood illnesses in Nepal.

Here we have uploaded the latest CBIMNCI protocol book in pdf format for your reference. 

You can either refer it here or please download for future reference.

Download CBIMNCI (CB IMNCI) protocol

Community based integrated management of childhood and neonatal illness protocol has been developed by government of Nepal, child health division. This protocol has been the main guidelines for Nepal.

There are these protocols and guidelines developed for health care workers in Nepal.

1. CB-IMNCI (CBIMNCI) guidelines for FCHV pdf
2. FB-IMNCI (CBIMNCI) guidelines for Paramedics pdf
3. FB-IMNCI (CBIMNCI) guidelines for Medical officers pdf
4. CB IMNCI flipchart pdf
5. CBIMNCI remote area  guideline pdf
6. CBIMNCI program management module pdf

The complete guidelines can be downloaded below.

CBIMNCI remote area  guideline pdf (imnci chart booklet)

Here i CBIMNCI remote area guideline in pdf format to download and to read.

https://drive.google.com/file/d/1WMK9YeiYR0dIDPU9zaPvNEhZdRS2h5g0

CBIMNCI program management module pdf (imnci chart booklet)

Here is CBIMNCI program management module.

https://drive.google.com/file/d/11JiJMVooK7RVd2ER7O6yA5OMWdiOOF7O/preview

CB IMNCI flipchart pdf (imnci chart booklet)

Here is CBIMNCI flipchart for you to read and download.

https://drive.google.com/file/d/1cCVNF0ysFCYSYcKbwPCAlF8ZJ-cW1agS/preview

FB-IMNCI (CBIMNCI) guidelines for Paramedics pdf (imnci chart booklet)

https://drive.google.com/file/d/1z6XL030saQUPqacVJ4EKi5Euk7RwVDOj/preview

FB-IMNCI (CBIMNCI) guidelines for Medical officers pdf (imnci chart booklet)

https://drive.google.com/file/d/1S0ji6gsJyeSvbgdsV1hqVabhiSMkTkIj/preview

CB-IMNCI (CBIMNCI) guidelines for FCHV pdf (imnci chart booklet)

https://drive.google.com/file/d/1JE6Olq1Ko1oa8gs3jlpkEQeNq0_y9foA/preview

Download CBIMNCI (CB IMNCI) guideline (imnci chart booklet)

Please use this link for downloading the book in pdf format. These guidelines are updated accordingly to date of this post and updates will be posted subsequently.

Difference between CBIMNCI (CB IMNCI) and CB-IMCI

CBIMCI stands for community based integrated management of childhood illnesses. This guideline is the past form of CBIMNCI.

CBIMNCI was developed with addition of neonatal illnesses guidelines to the childhood illnesses. The main reason for this was that childhood illnesses cannot be separated from neonatal illnesses.

CBIMCI was also derived from IMCI (read below).

Definition of IMCI

IMCI stands for integrated management of childhood illnesses. As the childhood mortality rate in our country were relatively high this must have been addressed quickly and in a economic way. For this, healthcare workers like CMA, HA and volunteers like FCHV needed to be trained and upgraded to manage childhood illnesses. 

Gradually, this protocol was update to change into CBIMCI and subsequently into CBIMNCI and FBIMNCI.

IMCI vs IMNCI

The main difference between IMCI and IMNCI is that IMNCI includes neonatal ilnesses. 

Lately, IMNCI is updated into FB-IMNCI (Facility based integrated management of childhood and neonatal illnesses )

Timeline of CBIMNCI Nepal

IMCI-CBIMNCI-FCHV-PARAMEDICS-MEDICAL OFFICER-FBIMNCI

(See Picture below)

What are disease covered by CBIMNCI nepal?

Following diseases are covered by CBIMNCI and FBIMNCI Nepal.

1. Diarrhoea and AGE
2. Fever
3. Otitis media (ear infections)
4. Vomiting and dehydration
5. Feeding problems

Should doctors follow CBIMNCI protocol Nepal?

Yes. There is a separate FBIMNCI protocol for medical officers. 

The protocol is different for rural and urban area as well. 

When was latest CBIMNCI guideline updated in Nepal?

Latest guidelines was updated in 2021 AD. The exact date of patest protocol are mentioned in the guidelines books above. Please refer to pdfs above.

Is CBIMNCI Nepal approved by WHO?

YES . CBIMNCI guidelines are guided and developed with help of WHO.

These guidelines can also be downloaded by visiting WHO website. 

Where can I download CBIMNCI guideline Nepal?

Please download the guidelines from links above. 

If you want to download in bundle refer this link. 

Related links:

1. WHO
2. Child health division
3. Family welfare division
4. Dr Health Rx
5. Ministry of health and population 

Table of Contents(toc)

Tear gas, commonly used in crowd control, consists of chemical irritants such as chloroacetophenone (CN), chlorobenzylidene malononitrile (CS), and dibenzoxazepine (CR). While classified as a “riot control agent,” its effects on human health can be severe, particularly with prolonged or high-concentration exposure. 

Here are key risks supported by scientific and medical literature:

1. Respiratory Effects

• Acute Respiratory Distress Syndrome (ARDS): High exposure can lead to severe lung injury and ARDS, particularly in individuals with pre-existing conditions such as asthma or COPD.

• Bronchoconstriction & Asthma Exacerbation: CS gas can trigger acute bronchospasm, posing a significant risk for asthmatics.

• Lung Damage & Chronic Bronchitis: Prolonged exposure may result in chemical pneumonitis and chronic respiratory symptoms (Karagama et al., 2003).

2. Ocular Injuries & Blindness

• Severe Eye Irritation: Tear gas causes lacrimation, conjunctivitis, corneal abrasions, and in some cases, permanent vision impairment (Hu et al., 1989).

• Risk of Secondary Trauma: People often rub their eyes vigorously, leading to corneal damage and infection.

3. Skin Burns & Chemical Dermatitis

• Blister Formation & Irritation: CS and CN can cause second-degree burns, dermatitis, and allergic skin reactions (CDC, 2018).

• Delayed Hypersensitivity Reactions: Some individuals develop long-term skin sensitivity to tear gas chemicals.

4. Neurological & Psychological Effects

• Seizures & Nerve Damage: Reports suggest potential neurotoxicity with repeated exposure, including seizures in susceptible individuals (Papirmeister et al., 1991).

• PTSD & Anxiety Disorders: Tear gas exposure during stressful events has been linked to increased rates of PTSD, panic attacks, and acute stress reactions (Chorley et al., 2021).

5. Cardiovascular Risks

• Hypertension & Cardiac Events: Tear gas can increase blood pressure and heart rate, posing a risk for individuals with heart disease (Schep et al., 2015).

• Increased Risk of Heart Attacks: The sympathetic nervous system activation triggered by tear gas can induce myocardial infarction in vulnerable individuals.

6. Reproductive & Developmental Toxicity

• Increased Miscarriage Risk: Exposure to tear gas has been associated with miscarriages and menstrual irregularities in some studies (Karam et al., 2020).

• Potential Teratogenic Effects: Although data is limited, animal studies suggest possible fetal toxicity with prolonged exposure.

7. Long-Term Pulmonary & Systemic Effects

• Pulmonary Fibrosis & Chronic Lung Disease: Persistent exposure may lead to lung fibrosis, similar to occupational chemical exposures (Weisenburger et al., 2020).

• Potential Carcinogenicity: Some solvents used in tear gas formulations have been linked to DNA damage, though direct human studies are lacking.

Conclusion

Tear gas is not a harmless deterrent; it poses significant acute and chronic health risks, particularly for vulnerable populations (children, elderly, and those with pre-existing conditions). Its use in enclosed spaces or at high concentrations greatly increases risks of severe respiratory, ocular, and systemic effects.