(Listen to the first part of this report.)
I’d been wanting to return to Chimling Village in the hills of Sindhupalchowk district since soon after my first visit in March 2021. That’s when I accompanied health workers to find out the status of women who had given birth recently, but had delivered their babies at home. In particular, I was curious about their experiences with misoprostol, a drug that’s given to pregnant women who might deliver without the support of a skilled birth attendant. The main cause of death in home deliveries in Nepal, and elsewhere, is excessive bleeding after the birth; misoprostol is meant to stop that.
The visit was a real eye-opener. I found out that of 10 women who had recently given birth at home, only one, Dilmaya Tamang, had received the pills. And she got them only because a visiting health worker had spoken to the female community health volunteer responsible for the village, who happened to be Dilmaya’s sister-in-law and neighbour, before Dilmaya gave birth.
That specific incident was troubling, but I think what bothered me most as I returned from my trip was the casual attitudes I found in many people involved in providing health services. In some cases the health care given to mother and child could easily mean the difference between life and death.
So, I was happy to see that Dilmaya and her neighbour Priya were healthy, as were their nine-month-old babies. The one woman in the village currently pregnant told us that she was planning to deliver in the birthing centre—another piece of good news. When we visited the centre in March the building was complete but equipment and drugs were not on hand and essential staff had gone for training.
But then we heard about a home delivery that had taken place nearby a few days earlier. We could get few details from the birthing centre, so we went to speak with the new mother and her family, a conversation that brought back my earlier fears about health care in the hills of Nepal.
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Nagendra Jung Shahi 0:14
Mankha is a newly established birthing center. It is running from six to six, six to eight month.
Before we start doing the birthing center, people were going
to [a nearby] hospital or another — Barabise PHC — for the maternal and neonatal service. After establishing a birthing center in Mankha, . now, MCH services utilization by local people and institutional delivery and ANC was increasing.
Marty Logan 0:43
That's Nagendra Jang Shahi from the nonprofit health organization, One Heart Worldwide. He's explaining about the building of a new birthing center at the health post in this area, formerly known as Mankha Village Development Center. It means that women now have another option to traveling down the hill to larger health facilities to deliver or do their pre and post birth checkups.
With our driver Shambu we are grinding up a rocky mountain road in a jeep toward the village of Chimling in Balephi rural municipality Sindhupalchowk district.
Alone in the backseat, I stop myself from bouncing around by grabbing the strap hanging above the door, or by bracing my arms on the seat bottom.
It rained last night. So instead of churning through inches of dust-raising dirt as we angle upwards, like we did on our previous trip in March 2021, we rumble steadily over the jarring road, past banana palms and other small trees near the roadside, while taller trees and hills loom ghostly in the morning fog.
Welcome to the Nepal Now. My name is Marty Logan.
I've been wanting to return to Chimling village in the hills of Sindhupalchowk district since soon after my first visit in March 2021. That's when I accompanied health workers to find out the status of women who had given birth recently, but had delivered their babies at home.
In particular, I was curious about their experiences with misoprostol, a drug that's given to pregnant women who might deliver without the support of a skilled birth attendant. The main cause of death in home deliveries in Nepal, and elsewhere, is excessive bleeding after birth. Misoprostol is meant to stop that.
That visit was a real eye opener.
I found out that of 10 women who had recently given birth at home only one, Dilmaya Tamang, had received the pills. And she got them only because of a visiting health worker had spoken to the female community health volunteer responsible for the village who happened to be Dilmaya's sister-in-law and neighbor, before Dilmaya gave birth.
That specific incident was troubling. But I think what bothered me most as I returned from my trip was the casual attitudes I found in many people involved in providing health services.
In some cases, the health care given to mother and child could easily mean the difference between life and death.
So I was happy on this trip to see that Dilmaya and her neighbor Priya were healthy, as were their nine month old babies.
The one woman in the village currently pregnant, told us that she was planning to deliver in the birthing center. Another piece of good news.
When we visited the center in March, the building was complete. But equipment and drugs were not on hand, and essential staff had gone for training.
But then today, we heard about a home delivery that had taken place nearby a few days earlier. We could get few details from the birthing center, so we went to speak with the new mother and her family, a conversation that brought back my earlier fears about health care in the hills of Nepal
Just over half an hour after turning off the highway, now far below, and starting this climb we reach the local primary school and stop the jeep. The fog is starting to break showing blue sky and the almost vertical hill that looms over Chimling. A few meters away, a small group of women are sitting on a blanket at the roadside. They're cleaning recently picked millet grains using round woven trays called nanglo.
They hold the tray in front of them on either side, then flick their wrists upward so the contents rise into the air.
Grains fall back onto the nanglo while the chaff gets blown away by the wind.
Nagendra tries his hand at it, and then women giggle.
Then I see that Neermaya, the female community health volunteer who guided us in March, has arrived. We say our greetings and follow her along the dirt path that leads to the small community.
Both women we met last time deal, Dilmaya and Priya, are well as are their babies and the rest of their families. Neither reports postnatal health issues or any health problems.
And there is more good news. When we visited this community in March, the last 10 deliveries had taken place in women's homes. Since then, only one woman has delivered here and that at the new birthing center.
Neermaya takes the credit, saying she convinced the woman that it would be better for the baby's health, and that she would get money from the government for using the health facility.
We say goodbye and return to the Jeep for the 10 minute ride downhill to the health post and birthing center.
in March 2021, the center was brand new, but not being used because nurses were away for training and essential equipment was not in place. Today Nagendra does a quick inventory and is satisfied with the equipment and the stock of drugs on hand. We also learn that more than a dozen women from the area have given birth here since the center opened.
While at the center, a staff member tells us about a home delivery that happened nearby recently. The three of us climb into the Jeep, drive for five minutes, and walk for 15 more along a pothole dirt road to arrive at the house of the newborn and her family.
Santoshi Tamang is 22, her daughter just three days old. The young woman studied till grade eight, got married when she was 15, and has a four-year-old son.
She sits on a makeshift bed in front of the family's small home as her mother fusses with the baby and her son plays nearby.
Santoshi tells us her daughter arrived unexpectedly one night 15 days before her due date. She thought the pains might simply be gas. But by the time she and her parents realized what was happening, they decided it was better to stay put. About three hours later, just before 3am, the girl was born, with no complications.
Her story is not surprising. Although Santoshi's son was born in a hospital in Katmandu, as I've learned, people in this area are used to giving birth at home, and many are still convinced that it's the best option.
As we're talking to Santoshi her father arrives. He reinforces the point that the family was prepared for the baby to be born about two weeks later, and that by the time they realized what was happening on that night, the delivery had already happened.
Unknown Speaker 8:22
[A mix of Nepali and English follows]
Marty Logan 8:49
But there are other things about this story that bother me. We discuss them as we walk back to the Jeep. First, the female community health volunteers assigned to this area didn't visit Santoshi once during her pregnancy, although it's part of the FCHV mandate.
We're told it's because she lives in the highway town below, in other words, an inconvenient distance away. But that's not very convincing.
Also, when we arrived today, we were the first people from outside, including the health post, to visit.
We were told that was because the nurses trained as skilled birth attendants were away. But we know that other nursing staff were available—yet they didn't make the short trip to check on the condition of mother and baby.
I told the story to Dr. Lhamo Sherpa, who we featured in our previous episode—Women's Empowerment is the Best Medicine. Although trained in epidemiology, throughout her career she has focused on women's health and empowerment
Dr Lhamo Sherpa 9:57
When I was the director
of Himalayan Health and Environmental Services Solukhumbu, I had attended a national health review meeting, in 2013. And at that time, they were discussing about birthing centers. So what they had done while preparing the birthing center was that if it is in a mountain area, there are less people. So let's provide less number of nurses. If it is in the Tarai [plains], they have more people. So let's provide more nurses. But every birth is you know, critical. And every maternal health must be taken as a very important event for the mother and the baby. So that's why we cannot have a birthing center based on the number of individuals living in that particular area, and then assign only one nurse based on the population. So that was my argument. At that time. I think they changed it to two. But I think still two ANMs [auxiliary nurse midwives] are not adequate to provide all the services for 24 hours, 365 days a year.
Marty Logan 11:10
It's not only that rule that needs to be changed, says Dr. Lhamo, the entire approach of the healthcare system needs refocusing.
Dr Lhamo Sherpa 11:19
Nepal Government has a policy to start their health post at 10 o'clock, right. And then by two o'clock, the checkup is done. From three until five, they have to do administrative work. So for them, it's like they don't have a duty to go beyond that health post. So that is the mentality of most of the health workers. Which is why I say that our health system is not human centered. It is facility centered, which is why I've been saying from the beginning of this COVID that our entire health system needs to be women centered, it should be human centered. Unless women or anybody comes to the facility, they will not get services at home. So how can we bring services to them? I mean, what do they want? That is more important.
Marty Logan 12:21
Thanks to Lhamo Sherpa, and everyone else who spoke to me for this episode, especially the women in Chimling village for again putting up with our brief intrusion in their lives.
Thanks also to One Heart Worldwide, who provided the Jeep for the trip to Balefi, and to Nagendra for showing the way.
If you enjoyed this episode, I encourage you to listen to the first part of this story. It's called No Magic Pill, and is available on every podcast player where you find Nepal Now.
By focusing on immediate maternal health issues, it's easy to forget the progress that Nepal has made in providing health care to women and children and to all of its people. I don't want to ignore that. And I think that listening to the first episode will help provide that perspective.
Please consider rating or reviewing Nepal now on Apple podcasts. It takes just a minute and we'll make it easier for others to find us.
My name is Marty Logan. I produce the show and I'll talk to you again soon.
Transcribed by https://otter.ai