Namaste Friends! Winter has nearly left us; however it is still very, very cold in most of the PHASE field posts around Humla and Gorkha regions. Despite winter, our staff have been working consistently for the last two months in the snowy regions. It is all possible because of your generous support.
Early pregnancy is one of the major causes in maternal deaths in rural areas of Nepal. Social factors such as culture, traditional practice and social status influence early age marriage in much of society, which leads to early marriage and then early pregnancy. To highlight this, let us share a story about teenage/early pregnancy in Maila village. Friends! Meet Rupshila Sarki of Maila village. Rupshila Sarki is a 17 years old girl married to Chandra Bahadur Sarki for the last two years.
Rupshila recalls – “When I was 15, my parents arranged my marriage to a 19 year old boy, Chandra Bahadur Sarki. We lived happily until a year passed but after this time, my in-laws started to look at me strangely. I did not care for a month or two about their weird behaviour but then they started to discuss pregnancy. I came to understand the reason why they looked at me strangely - They wanted me to have a baby soon!”
At first, Rupshila did not overly worry about her in-laws’ demand, thinking that every in-laws wants and deserves grandchildren. Chandra also did not listen to his parents. But Rupshila became stressed when she went to her parental home.
She says – “When I went to my parental home, both of my parents insisted that if I did not become pregnant within a month or two they will not allow me to visit my parental home again. They kept reminding me of the importance of having a baby. They also reminded if I do not become pregnant soon then society will cast doubt upon me; including my relatives.”
In this area, it is believed that if a married couple do not have baby within a year or two then it is because they did something wrong in a previous life. On the other hand, having a baby is seen as a symbol of prestige and status. Rupshila’s parents and in-laws did not want their family status to suffer.
Rupshila continues – “I was not able to think clearly. I did not want to become pregnant that soon. I used to sit in the community health education sessions run by PHASE staff in the village and came to know that early pregnancy is harmful to both me and the baby. But on the other hand, I could not bear the force from both my parents and my in-laws. I talked with my husband and decided go to the health post for counselling the very next day. I went to health post and met two PHASE sisters in the post. They took me inside the separate room when my turn came. I told them everything about my family problems.”
Rupshila had chosen the right place to go at the right time! PHASE staff gave her some advice about the risks and realities of early pregnancy and asked her to come again as soon as possible with her husband. When she was on the way to home she met some village women carrying fodder from the jungle. They asked her whereabouts and she explained, giving them the details. Rupshila found out from talking to her friends that there was also a rumour in the village that Chandra – Rupshila’s husband- has a problem with his reproductive system, which was preventing Rupshila from becoming pregnant.
Rupshila struggled to say – “When I heard about my husband’s problem from friends I felt like I was buried down in the earth; however after a while I also felt quite comfortable because there is no problem with me, it is all because of my husband. I planned to tell the facts to all my parents and in-laws and they will start to blame on my husband instead of me. I reached home and told my husband that PHASE sisters want to meet both of us together at the health post. I did not mention the rumours about his problem. The very next day, we went together to the health post. PHASE sisters took us inside the separate room and asked us about our education, family background and marriage date etc. They started to advise us about the risks of early pregnancy. They said best time to become pregnant is between 20 to 35 years of age. Whilst we are still young, the reproductive organs in our body are still developing, so it may cause vaginal bleeding and abdominal cramps which lead to miscarriage, placental abruption and placenta previa, premature birth and ectopic pregnancy as well. They also informed us that early pregnancy may lead to swelling and pregnancy induced hypertension. I felt scared and worried after hearing all their advice, and promised not to become pregnant before 20 years of age; my husband was also committed to do so. After a long counselling session, PHASE sisters advised us to bring our parents if they continued to insist on my becoming pregnant. I was happy but nervous on other hand. My parents and in-laws never stop insisting about us having a baby.”
Rupshila was happy but nervous. She was scared about the reaction from her parents and in-laws. On the way to home, she discussed with her husband and decided to take both their parents to the health post to clarify the reasons why she does not want to have a baby sooner.
“At first, my parents did not agree to come to the health post since they live in 4 hours walk away. Also, they were upset with us because of taking advice from health staff. They were upset and said that we ruined their social status by going to health post to stop pregnancy. They also said- they were only 19 when they had their first baby, and have had 6 children without any problem. They also said this is a natural gift; we have to accept it as soon as possible without delay.” Rupshila further adds – “I ignored their reproach and said calmly that PHASE sisters are good and they will give us the way to become pregnant in healthier way as soon as possible. After refusing for a while, they agreed to go the health post thinking that they will become grandparents soon. We six including parents and in-laws went to the health post after a week. PHASE sisters were in their usual duty. After half an hour, they called us inside. We all entered into the separate room. PHASE sisters greeted all of us and started the conversation from wellbeing and usual daily lifestyles. After a while they repeated the same counselling again with my parents and in-laws. They queried that if anything happens to me who will be responsible? If I am not in perfect health then how can I give birth to a healthy baby? They incorporated several examples of risk and dangers in early pregnancy and convinced our parents that it would be safer to have a baby after three years. After the counselling both parents were happy and promised not to force me until three years. We thanked sisters for their help and support. We returned happily to our home.”
PHASE staff organizes community health education session, door-to-door home visits, clinic health education session and school health education session every three days in a week. Rupshila attended the events and kept in mind that early pregnancy is dangerous. This helped her to avoid the possibility of early pregnancy.
Thank you very much for your generous support!!!
Please help us continue our work in Maila so that women and children can get the health service they need.
Friends! Our field staff have already reached their respective work stations after the long holidays of Dashain and Tihar festival. Between the festivals they got several trainings- Dental Training, Obstetric Training and some of them also received Women Empowerment Training in Kathmandu.
This time we would like to share the story of a malnourished child in Maila village: Kamala Jaisi is an 18 year old married women living in Maila village.
Kamala explains, “I often take part in mother’s group meetings organized by PHASE health workers in my village. I have learnt a lot of things about antenatal care during health education sessions. Health staff also taught us about danger signs during pregnancy.”
Some months after her marriage, Kamala got pregnant. She knew about antenatal services provided by PHASE health staff in the health post. She went for her regular antenatal care in the health post and the health workers gave her iron tablets and Albendazole to prevent anemia and worms.
Kamala remembers, “I went to the health post for antenatal check ups regularly. The PHASE sister said that everything is normal and good. In the 8th month, one day in the afternoon I felt a pain inside my tummy. At first I did not pay attention to the pain but it started to increase slowly and I could not bear it. I hurried to the health post. There I met the PHASE sister and immediately asked her about my pain. She checked me and said that it is labour pain, do not worry about pain it will increase a little more till you give birth. I was shocked to know this because it was just 8th month. I asked the PHASE sister about my date. She explained that sometimes this may happen and it is called premature delivery. After an hour or two, I gave birth to a baby.”
Kamala gave birth to a baby boy in the 8th month of pregnancy. It was her first baby and because it was premature it was underweight i.e. only 2100 gram. PHASE staff taught her about the care of a premature baby and reassured her that everything will be fine.
Kamala says, “The PHASE sister said I have to breastfeed 8 times in a day, but unfortunately I could not do that because my breast was small and it did not produce enough milk. I went to the health post again and explained my problem. They taught me a different technique but it did not work again. They also advised me to feed boiled cow milk after mixing certain portion of water and sugar in it, as maybe my baby was too small and was not able to nurse well. I tried to feed cow's milk but my mother-in-law refused to do so. It is believed that feeding cow's milk makes the spirits angry which may harm the baby. Also, I was busy with regular household chores and could not take care of the baby too much except trying breastfeeding time to time.”
Kamala was very busy tending the fields and her normal household chores. She could not take care of her baby intensively. Her baby could not grow well and got thinner.
She recalls, “My baby was getting too thin – he even could not cry loudly. My husband said that I had given birth to a curse and a sin of a previous life in the form of our baby, which will leave us soon and we will have only suffering and painful memory with us. He kept ignoring him and even refused to hold the baby, trying to avoid even looking at him"
In this community, there is still a belief that when someone has an abnormal or disabled baby in the house it is because of a curse or a sin from a previous life. Most people do not try to treat their abnormal or disabled babies because of this superstitious belief among the society.
“One day, the PHASE health worker came to my house during her regular routine of door-to-door health education sessions. The PHASE sister smiled when she saw me and asked me about my wellbeing and baby’s health etc. I could not speak in front of her. I just showed my baby. Tears dropped from my eyes. She exclaimed with fear and anger seeing my thin baby.” Kamala recalls, “the PHASE sister yelled at me because of not taking my baby to the health post even after this situation. She was also angry because of not feeding cow's milk according to her advice. I explained PHASE sister the reasons of not being able to feed cow's milk and visit health post.”
Kamala’s husband and mother-in-law refused when she wanted to go to the health post for advice. People in this area believe that it is not good to take babies and small children out of the house because a bad spirit may catch them.
“After my short explanation, the PHASE sister called my mother-in-law and husband outside the house. She requested us to sit together on the floor mat. She started to explain about baby health, baby feeding technique slowly and clearly. She clarified to my husband and mother-in-law that my baby is suffering from malnutrition.” Kamala adds, “Sister requested me to bring a small half bowl of boiled cow's milk. After that she demonstrated to mix water and sugar in it and taught us to feed the baby. She clearly explained that no bad spirit will harm my baby if I feed cow's milk. She advised me to feed cow's milk every two hours. She also reminded me to bring the baby to the health post after two weeks.”
Now, Kamala’s husband and mother-in-law were also convinced and they allowed her to feed cow's milk. Kamala fed her baby with cow's milk according to the advice of the health staff. Her baby easily swallowed the milk. After a week she started to notice changes in her baby. She got excited and kept feeding her baby happily.
“My husband and mother-in-law also helped me making milk for baby. I kept feeding the baby in two hour intervals. After two weeks, my baby’s face became lovely, his skin also started to look soft and healthy. I went to health post with baby. This time, my mother-in-law and husband both were happy and they allowed me to take baby to the health post.” Kamala says, “When I reached the health post, sister was very happy when she saw my baby getting better! She weighed my baby. She said it is improving and advised me to continue feeding cow's milk. After 3 months I started to feed ready-made formula bought in the market. PHASE sister also advised me about vaccinations and the correct time for weaning. I kept going to health post every month. Now my baby is 8 months and 9 Kg – the right weight.”
Malnutrition among young children is a common problem in Maila because of the factors described above: Young mothers often have very little time to care for their babies, and mothers in law often still follow unhelpful ancient traditions. Prejudice about what is and isn't good for small children, and worries about the bad luck attached to ill and disabled babies contribute to the effects that poverty and lack of alternative feeding sources can have. As Kamala's story illustrates, these factors are not insurmountable: because PHASE staff are trusted and known in the community, they can often persuade families to depart from tradition and follow their advice.
Kamala did not forget to thank health staff for their continuous help and support.
Sakuntala Jaisi is a 22 year old young mother from Madana, a village approximately 6 hours walk from Maila health post. She had her first baby, a little girl, a few months ago, ably assisted during the birth by the PHASE health workers.
Here, we are not focussing on her delivery, but on the events leading up to and during her early pregnancy, which demonstrate the wide range of problems our health workers deal with:
“I come from a poor and remote village, my parents are farmers and my father sometimes goes to Simikot (district headquarter of Humla) to work for a local trekking company, to increase our income. I went to school for 3 years but then dropped out to help my mother with all the chores, looking after the younger children and the animals and working in the house and on the fields. When I was 19 years, my parents arranged a marriage for me with a young man from Madana village, and I moved in with my parents in law. Life was OK with my new family, except that I missed my mother and sisters. But after about a year of married life, my mother in law began to question me every month because I had still not fallen pregnant.
I had not told her – or anyone – that my womb was dropping down and causing me quite a bit of discomfort when walking, and I was worried that this might be the reason that I wasn’t falling pregnant. I tried to keep this from my husband as well, and always pushed my womb in with my hand before we had marital relationships.”
Sakuntala is one of many women in Nepal who suffer from uterine prolapsed. In most countries, this is a problem mostly seen in older women who have had many children, but for reasons still not quite clear (probably related to malnutrition and hard labour), in Nepal even young women can be affected. Uterine prolapsed is not a life threatening condition but can cause discomfort, bleeding and discharge and often women feel very embarrassed about it.
“After about 2 years of marriage, the pressure to have a baby was getting bigger and bigger and I was getting very worried that my mother in law would ask my husband to take another wife, even though he really loved me and told me he was not worried about me not having children. I had heard that in Maila health post a new organisation, PHASE, had started working and that the health workers there were very good and had helped many people. I decided to go there in spite of my embarrassment about my condition. When there was a group of other people from the village planning to go to Maila for treatment, I joined them, but I was worried that I might have to tell about my problem in front of them, so I thought up an alternative story of headaches and back pain in case I couldn’t speak to the health worker alone.”
Sakuntala needn’t have worried: In all PHASE health projects, great emphasis is placed on patient confidentiality, and the health workers always make sure they see individual patients in a separate room.
Sakuntala described what happened next:
“I was really shy about the story, but when I told them about not having had a child in two years marriage, and the kind sister asked me about other problems, such as my periods or problems with my womb dropping, I told her everything. The sister then examined me – I had to cover my face for embarrassment – and placed a soft ring inside me that kept my womb up. Even on the way home to Madana I felt the relief of the treatment.”
PHASE health workers are all trained in the fitting of rubber ring pessaries, which is the best treatment for young women who still want to have children. Older women might opt to have an operation, but this is not always easily available.
Amazingly (we don’t really have a scientific explanation for this), Sakuntala fell pregnant within 2 months! Her troubles were not over, however:
“One day, about 2 ½ months after I had first missed my period, I noticed that I was having trouble passing urine. It didn’t hurt, but only a few drops seemed to be coming out every time I went, even though I really felt as if my bladder was full. This got worse very quickly and by the next day I was unable to pass any urine and I was in great pain with a swollen abdomen. I told my husband – “there is something very wrong, we must go to the health post in Maila as soon as we can”. – It was a big struggle to get all the way to Maila, I was in so much pain, and the path that usually takes 6 hours to walk took us 9 hours instead. I felt near to fainting many times and just collapsed on the floor outside the clinic when we finally got there. The nurses quickly asked what had happened and realised that something must be blocking my urine from passing out of the bladder. They passed a small tube into my bladder, and although that hurt a little, the relief when the urine came out was great. They advised me and my husband to stay overnight, to make sure that I could pass urine on my own.”
Unfortunately, by the next morning, Sakuntala’s bladder was full again – the growing womb was just exactly the size to fill the whole pelvis and press on the urethra, the small urine vessel from the bladder, and block it. The nurses used a catheter again, but then the question was what to do next? Sakuntala couldn’t stay in Maila, she had work back home, and she couldn’t come back every day to have a catheter – ideally, this needed to be done at least twice a day.
Although the PHASE health workers hadn’t seen such a case before, and hadn’t been told what to do, they came up with the right solution: They taught Sakuntala’s husband how to catheterise her – including how to wash his hands and sterilise the catheter!
Sakuntala takes up the story:
“The nurses very carefully taught my husband how to use the small tube and how to keep it clean so my bladder wouldn’t get infected. I was still quite embarrassed about it all, but it was better than the pain when I couldn’t empty my bladder at all! Luckily, I found after about a week at home that I was suddenly able to pass urine freely again and so we didn’t have to use this treatment very often!”
Once the womb becomes bigger it will push itself out of the pelvis into the abdomen and will then not press on the urethra anymore. If Sakuntala hadn’t had treatment in time, she might well have died of kidney failure in early pregnancy. The presence of the PHASE health workers probably saved both her and her unborn baby’s life, through a very simple intervention which even her husband could do, once he had been taught!
Please help us continue our work in Maila so that women and children can get the health care they need when emergencies like this arise.
Dear Friends, Namaste!
Maila is a steep and hilly village like many other hill villages in Nepal. In Maila, most of the livelihood and household activities are strongly linked up with traditions of hundreds of years. We would like to introduce a boy from Maila village who suffered from all aspects of interlinked tradition and geographical snags.
“I am Subash B.K., a parentless boy aged 15. My father died when I was 5, and mother left the home. I live with my grandparents who are almost in their sixties; suffering from lung disease, blindness and physical disabilities.”
Subash B.K. is a boy from the Dalit (lower caste according to Hinduism) community. He became parentless in his childhood. His grandparents took care of him when he was child.
“My grandparents took care of me when I was a small child. My grandpa enrolled me in a local school when I was 8. By the time, my grandparents got older and they were physically too frail to work in the fields. Then, I had to take care of my grandparents. I dropped out from school after second grade.”
Subash’s grandparents got older and both of them are suffering from lung disease, blindness and physical disabilities. In Maila village, most of the old generation people smoke home-made tobacco. Tobacco is directly connected with the social traditions of Maila village. They produce tobacco in their own field. They also use tobacco as a special gift for relatives and friends. Smoking tobacco is the main cause of lung disease in this village.
“Instead of my grandparents, I started to work farming the fields. I had to take care of the cattle. Every day, I used to take cattle to the grazing field and collect firewood to cook food at home. Also, I had to collect fodder and grass for the cattle from steep and rocky hills.”
Subash had a big responsibility to take care of his grandparents, all the household chores, farming fields and cattle. He says;
“One day, as usual, I took cattle to the grazing field. Some other people from my village also came with their cattle. While I was in the jungle, I saw a tree with dried branches and thought it would be good to cut the dried branches for firewood. I climbed on the tree and started to cut the dried branches. Suddenly, I fell down on the ground from high up on the tree. I had not noticed that the branch on which I was standing was dried and brittle because of rain water.”
Subash fell down from the tree while cutting firewood. Many people fall from trees and from the steep hills and die while collecting firewood, fodder and grass in the hilly regions of Nepal.
“I did not know what happened after that, but when I woke up from the coma I found myself in Maila Sub-Health Post surrounded by villagers and health staff. Villagers said that they had found me unconscious on the ground and they took me to the Health Post and also informed my grandparents. I had a deep pain in my body, I found both my hands and legs were bandaged. Tears dropped down from my eyes because of pain and anxiety. I saw PHASE staff sister and CMA – Community Medicine Assistant - sitting next to me. They gave me an injection, I felt a lot of relief after that. They examined my fractured hands and legs. They said both of my legs and hands were critically damaged; skin and muscles are torn by the cracked bone. They advised me to go to Nepalgunj (a big city of western Nepal) for hospital treatment.”
Subash’s hands and legs were all broken in several places. He was in need of treatment by an orthopaedic specialist. Sub Health Posts such as Maila are the smallest unit of primary health service where complicated cases cannot be treated. PHASE and government staff informed Subash and his grandparents about the likely complications of his fracture injuries and suggested to take him to the well equipped hospital.
“We have very little agriculture land with no other source of income. I am only 15 years and my grandparents were old age. My grandparents were helpless themselves and so was I. We could not manage money for my treatment. I requested health staffs for my treatment in Maila Sub-Health Post as much as possible. PHASE sister came to my house and dressed my fracture wounds. Both health staffs put splints on all of my fractured limbs and gave me some medicines.”
Subash could not go to a well equipped hospital in the city because of financial problems. There are no funds either with the government or with PHASE as an NGO to finance this kind of treatment, which might cost as much as running a primary health care centre for a whole year. Subash had a long period of bed rest in his home and PHASE staff tried to treat him as much as possible. His neighbours helped him a lot for looking after his grandparents and managing the house and his cattle.
“PHASE sister regularly came to my house for follow up. She encouraged me in many ways. I would like to thank my neighbours who took me up to the health post. I would also like to thank PHASE sister for her encouragement and treatment. After a long rest, I could move myself here and there with great difficulty. My wounds are fully recovered now but fractured leg and hand could not form into its natural place. My leg and hand are not in a natural shape so I can not move myself straight.”
Because of an accident caused by his hard and unsafe working conditions, Subash suffered a major injury which might well have caused his death if he hadn’t had first aid from PHASE staff. Because there is no operational hospital nearby and no transport facilities to the far off regional hospital, and because his family couldn’t afford expensive hospital treatment or a long absence of everyone from the farm, he now faces a life with avoidable disabilities. In many remote villages like Maila people cannot get the right treatment at the right time due to geographical and financial difficulties. Many people like Subash face accidents and became disabled due to lack of access to health services. PHASE specialises in providing primary health care services, but this case is an example where more is needed.
PHASE is currently raising funds to open a project in nearby Kolti Primary Care Centre (PCC), which is a higher level of health institution with X-ray and lab facilities and a few in patient beds. This PCC has not been operational for many years – if it had been staffed and running well at the time of Subash’s accident, he might have been able to get there and be treated for his injuries and he could have avoided ongoing disability.
With our ongoing support, we will be able to further improve the health services to this very disadvantaged region so that people in Maila village can access the treatment they need. By opening a health project in Kolti, we hope to be able to prevent sad stories like Subash’s in future.
This time, we would like to talk about the tricky issue of family planning – quite a taboo topic in Nepal and especially in the remote mountain areas where Maila is located. The traditional belief is that family planning goes against the supreme power of God. Also there are myths and fear surrounding its use – especially around the relatively safe and uncomplicated male vasectomy operation.
Let us introduce Dhani Jaisi, a 35 year old married lady from Maila village. She is the mother of five daughters and two sons. After giving birth to her sixth baby, Dhani started to take Depo Provera – a 3 monthly family planning injection, on advice from the PHASE health workers. She stopped taking the injection without giving any information to the sub-health post.
Dhani says, “I had already six children and I did not want more, so I was recommended Depo Provera – family planning injection. But after some time I stopped because I was bleeding heavily. Due to my responsibilities in the household I did not manage time to inform health workers about either the bleeding or my decision to stop.”
There was a vasectomy camp organized in Maila village. The purpose was to provide free family planning operations to interested men of that area.
She adds, “I requested my husband to go for the vasectomy operation. Health staff and neighbours also advised him to go. Everyone was saying to him that he already has a lot of children and if he has more it will burden his family.”
On other hand, Dhani’s father-in-law was against the vasectomy. He was worried that he had only one son and that something might happen to him during or after the operation. Dhani’s husband agreed with his father and refused to go. And of course, a few months later, Dhani became pregnant again.
Dhani says, “I gave birth to my 7th child. I am now mother of 5 daughters and 2 sons.”
You may remember that we wrote to you previously about the tradition of Chaupadi. This is where women stay outside of house during their menstrual period and during the delivery of a child. Dhani was not allowed to be in her house for 21 days during her delivery.
She explains: “During the time of delivery I lived in a small shed which we use to house cattle. It was rainy season and the roof of the shed leaked badly. My husband and other family members were far away in the house and did not notice the problem. My feet and body swelled because of never being able to keep myself dry throughout the delivery and in the period after. I was bleeding, I could not move and I could not breast-feed the baby.”
Dhani was suffering from post-partum haemorrhage (heavy bleeding) and she was ill because of cold and wetness.
“The morning after the delivery my husband came to see me. When he saw my condition, he immediately informed the Maila sub health post. The PHASE health staff arrived soon after.” Dhani adds - “Both the staff were surprised when they saw the conditions in which I had been living. They checked my health and gave me some medicines. They advised my husband to keep me warm and dry.”
PHASE staffs conduct a door-to-door community health programme three out of six days in a week. During these visits, PHASE staff talked to Dhani’s husband and father-in-law. They talked and gave demonstrations about family planning, malnutrition, and what the negative impacts of the chaupadi tradition can be.
After some days, Dhani and her husband came to Maila health post.
Dhani’s husband says “It is our social culture to keep women outside when she is menstruating or giving birth. I also admit that I was scared to go for a vasectomy. I ran away from the camp because of fear.”
He added, pointing to his wife Dhani “This lady has suffered a lot because of my mistakes. I realize that having a lot of children is a burden on my household. I am unable to feed my seven children well. I promise; I will go for a vasectomy when there is another camp nearby.”
Dhani says “From now onwards I will take Depo – the temporary family planning injection again. If there is any problem I will come back to the health workers for advice. If my husband gets a vasectomy then I will stop. I would like to thank the dedicated health workers in the sub-health post very much for all the advice they have patiently given my family. After a long story, we are now ready to use means for family planning.”
Friends, thank you for taking the time to read our story. Providing a health service in this remote area is challenging but ultimately rewarding, and slowly the health status of the area is changing. But we still have a long way to go.
On Wednesday 13th March (next Wednesday) Global Giving will be matching all donations made by 30%! Please remember the people of Maila on that day and consider offering your support. Whatever you can offer will go even further!
With gratitude and hope;PHASE Nepal Team
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