Ensure Safe Motherhood for Women in Rural Nepal

by One Heart Worldwide
Ensure Safe Motherhood for Women in Rural Nepal
Ensure Safe Motherhood for Women in Rural Nepal
Ensure Safe Motherhood for Women in Rural Nepal
Ensure Safe Motherhood for Women in Rural Nepal
Ensure Safe Motherhood for Women in Rural Nepal
Ensure Safe Motherhood for Women in Rural Nepal
Ensure Safe Motherhood for Women in Rural Nepal
Ensure Safe Motherhood for Women in Rural Nepal
Ensure Safe Motherhood for Women in Rural Nepal
Ensure Safe Motherhood for Women in Rural Nepal
Ensure Safe Motherhood for Women in Rural Nepal
Ensure Safe Motherhood for Women in Rural Nepal
Ensure Safe Motherhood for Women in Rural Nepal
Ensure Safe Motherhood for Women in Rural Nepal

One Heart Worldwide’s work in the hill and mountain districts of Nepal is well known across the country for its impact on improved maternity care. We are hoping we can continue to build OHW’s legacy in Madhesh Province (formerly known as Province No. 2), where OHW introduced its MNH program in 2022 for the first time. Madhesh Province, bordering the Northeastern part of India, is much different from the other areas we have worked in. Instead of vast mountain ranges, we are working in the southernmost region of Nepal where the terrain is mostly plains. Local government officials and rural health service providers are looking forward to learning how OHW can use its proven experiences to impact the health and well-being of people who give birth in Madhesh Province.

 

As the District Coordinator of Sarlahi, one of the eight districts of this province, I have an important responsibility to steer OHW’s program in the best way. I am a local citizen of this province, I know there are so many challenges but at the same time, I also see a lot of opportunities for us to make a meaningful impact to improve the government’s maternal healthcare services.

At first glance, any new visitor will see that the road access is much better in Madhesh than in hilly and mountainous areas of Nepal. Our transportation system is better and so the health facilities are also more accessible. However, life is hard for many communities and we have one of the highest maternal and infant deaths rates in the country.

Sarlahi has Nepal’s second-lowest literacy rate. During our baseline survey, we found that the level of knowledge and awareness around pregnancy is so poor, that a large number of recently delivered mothers and their families are not even aware of the existing government incentives (ex: cash incentives for institutional birthing). Most birthing centers are in poor condition and lack proper equipment and tools.

Many nurses are not trained as Skilled Birth Attendants (SBAs) and therefore their skill acquisition is lower than other parts of Nepal. 

There is low investment in maternal and neonatal healthcare and its infrastructure. 

A lot of government guidelines for quality birthing centers are not actively put into practice. 

We also found that cultural and social norms affect women’s decision-making. 

Women constantly need permission from male household members to even go to health facilities to obtain services. 

All of these and many other factors are putting the lives of many pregnant women, mothers and infants at high risk. 

OHW aims to address these issues and work in close partnership with local governments by providing technical support and contributing financial resources. The idea of partnerships with non-government organizations (NGOs or non-profits) in the health sector is quite new for our local government and there is already a lot of enthusiasm to learn and collaborate. We have been consistently coordinating with local government, health units and officials to work as partners and make MNH a priority in their development, planning, and budgeting. 

While there are several organizations working in the health sector in Madhesh Province, they are not fully invested in MNH and only work in a few municipalities. OHW is fully invested to make a difference and has been working in all 20 municipalities/local levels within Sarlahi district. 

Building new birthing centers and providing medical equipment is not enough - and we know that thanks to our conversations with people who live in the communities we work in. There is a need to allocate financial resources, involve government leadership and train service providers - all of which are key to making our MNH program a big success. 

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Nurse Rita
Nurse Rita

It was a night that Nurse Rita can never forget. Her patient, Bhavana, was an underage 17-year-old pregnant girl from remote Dumre Dara village. She walked nearly three hours to reach the birthing center at Bhalaydanda Health Facility of Udaypurgadhi Palika (rural municipality) of Udayapur district. She was already 16 days overdue. This was a complicated case that made Rita and her team of nurses quite nervous.

Nurse Rita was under a lot of pressure during this high risk delivery. She had to lead the team and make tough decisions to save both the mother and her baby. The mother’s blood pressure was exceedingly high after already having gone through a prolonged labor. She was having a hard time pushing out the baby, and the mother was in severe pain.

“This was the moment when I had to use the best of the knowledge that I had learned from my mentors from One Heart Worldwide, but I also knew this was the most complicated case I had ever handled,” says Rita.

After nearly two hours, the baby was born and that was when the real challenge began. The baby was born flat, which medically means that the baby has no muscle tone, is not breathing and has no heart rate soon after birth.

“All of us thought the baby had died, but we had to try our best to save the baby. I had less than a minute to give my best,” recalls Rita, still shaken with fear as she narrates her experience. She then recalled the ‘Golden Minute’ session during the Simulation Based Mentorship Program (SBMP) she had participated as a mentee.

The ‘Golden Minute’ means newborn resuscitation for babies born with asphyxia (deprived of oxygen), has to be initiated within one minute of delivery.

Nurse Rita quickly cut off the umbilical cord and put the baby on the resuscitation table and gave him electric suction. This helped the baby to start breathing. But the newborn still looked pale with no color and was struggling to cry. After 10 minutes, the baby began to cry but still didn’t sound normal.

At the same time, the mother’s condition was worsening. She was bleeding profusely and Rita sought help from a paramedic team to take care of the baby by ventilating him with an Ambu bag. Rita started taking care of the mother, who was in severe pain.

The baby was recovering but since there was no neonatal intensive care unit (NICU) at the birthing center, Rita made the decision to send the baby to a city hospital in Biratnagar, where the baby was taken care of and is now a healthy boy today.

“I remember how panicked I was but I built my confidence quickly with the knowledge I had gained during the SMBP and I can never forget how the clinical team from OHW had provided such great mentorship,” shares Rita.

 

A REWARDING CHALLENGE FOR RURAL NURSES - SAVING LIVES EVERYDAY

For Nurse Rita, working in the far-off government rural birthing center in Bhalaydanda village ward is challenging, but rewarding at the same time.

“It is not easy for the mothers to travel to the birthing center especially those who travel so far but we are always ready to give our best. Thanks to OHW, we have become better service providers,” says Rita.

She has delivered over 200 babies since she started working three years ago. OHW arrived in the rural municipality ward to provide support to the birthing center, which was under-equipped and the nurses lacked skills as most of them had not trained as Skilled Birth Attendants (SBAs) yet. Rita is the only trained SBA of the nursing team.

However, the non-SBA nurses have been able to develop their skills and knowledge through the SBMP training, provided by the OHW team. They have been able to get hands-on-training through the simulation exercises, as well as coaching and mentorship.

“Two of our nurses literally had zero knowledge and skills, but today after SBMP they are able to properly diagnose patients, carry on case findings and they have become such a great help to me. I alone cannot handle all the cases that come in and I would not be able to provide quality service without their help,” says Rita.

She acknowledges how the two nurses played a key role in saving the adolescent mother and her newborn. At the same time her team also helped to calm the families through counseling since they were panicking about the mother and baby.

Rita and her team also act as advocates and educators for behavioral change among families, who still do not have a lot of knowledge about the importance of institutional birthing.

Her own patient, 17-year-old Bhavana didn’t realize the risk of pregnancy. Despite several antenatal counseling sessions with nurses in her own village, she was adamant to give birth at home since she, herself, was born at home. She had also seen other babies who were not taken to the birthing center for delivery. She had been stubborn even when her delivery date was overdue for more than 16 days. It was only when she realized that she was putting herself and her baby at risk that she decided to head down to the birthing center.

“Ultimately, she made the right decision, but it was almost too late. She was lucky to survive. Saving her was so rewarding for us because this could also set an example to other villagers that it is not worth taking the risk of delivering at home,” says Rita.

Rita and her team continue to educate the mothers and their families whenever they visit the birthing center. The villagers often face the hardship of journey due to tough terrain, which itself can be very discouraging for them. There are hardly any vehicles available, and there is no ambulance service. Many have to walk for over 4 hours just to reach the birthing center.

“But no matter how hard the journey, it is worth traveling here because we are here to help them. Not traveling makes it even more risky for the mothers and babies,” says Rita. She shares that since OHW’s arrival in the village, the villagers have been given renewed hope with the new equipment, and constant support and encouragement from the OHW clinical team.

“This ‘Golden Minute"‘ is one example of how OHW’s support has made such a deep impact helping in our work benefiting the local communities,” says Nurse Rita.

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OHW’s support to local rural governments in the most inaccessible villages

OHW usually works in rural municipality wards like Sipali Chilaune. In rural areas of Nepal, local communities face many challenges to get access to quality maternity services. These are also the areas where local government health offices are faced with limited financial resources to develop local health capacity, buy equipment, renovate and build birthing centers. This is where OHW’s partnership model has helped to build local capacity - through cost-sharing, knowledge-building, management, and entrepreneurial skill development.

“This was our first project with a development partner on a cost-sharing basis. I was curious whether it was worth our investment. Now, I can see the impact and we want to thank OHW from the core of our heart for provide support to build the birthing center,” says government official, Parasuram Thapa, Chief of Roshi Rural Municipality. He explained how the local government had never tried such a joint investment approach for a community-based initiative.

It was also a very challenging time when OHW had approached the local government to collaborate on improving maternity care services. As the work started, the global pandemic had finally hit Nepal and several officials from the health post management committee were infected with COVID-19. The monsoon rain also added to their challenges and caused the river to flood, creating problems with roads and transportation. All of this made the supply and delivery of construction materials very difficult, causing them to halt construction for over five months. Despite these challenges, the work resumed and construction completed within 14 months. 

Birthing Center Before OHW Upgrades
Birthing Center After OHW Upgrades

“I feel we have made a lot of difference to improve maternity care services and one of our great successes has been to promote a feeling of ownership among local stakeholders. These stakeholders will help in the sustainability of maintaining a quality birthing facility in years to come,” explains OHW’s Rabin.

Such a feeling is echoed by local government officials who have been trying for years to provide quality maternity healthcare in the municipality. They shared how the impact has been mostly in an increase in institutional birthing that will eventually reduce the number of home birth deliveries. The partnership with OHW has also helped give them more ideas on how to design, build and financially plan for an affordable, quality birthing center.

“When I started working as Health Coordinator at Roshi Rural Municipality, I was very upset seeing the conditions of the birthing centers,” recalls Gangalal Shrestha, Chief of Health Section of Roshi Rural Municipality. He added how he tried his best but every effort his team made was ineffective as they lacked expert knowledge on creating an equitable healthcare system. Now with OHW’s help, he has seen a lot of change.

“After OHW stepped into our municipality, we gradually learned and collaborated with One Heart to strengthen our birthing center. After observing the transformation at Sipali Chilaune birthing center, we are all so proud to have a birthing center like this, which is better than any other facility in the whole district,” said official Gangalal.

 

Community education: A step further in OHW support

One of the biggest challenges is also lack of education and awareness around safe motherhood practices within the local community. This is where the OHW team has been able to promote community education about safe pregnancy and maternity care. 

“We have already started preparedness packages to educate about pregnancy complications and promoting misoprostol, and family involvement in the care of pregnant women in their households,” said Rabin. Rabin is OHW’s longest serving District Coordinator and has many years of experience in working with rural communities.

He shared how OHW’s clinical team has been working side by side with local health post nurses to educate families about the benefits of regular pregnancy checks, how to deal with complications, where to get help and who to contact for counseling and medical aid. OHW has also helped to provide awareness through interactions with household members and their roles in promoting the safety of pregnant women and mothers. 

In addition to in-person advocacy, OHW has also been working in partnership with a local radio station, Radio ABC, to disseminate information to local families by airing radio jingles about safe pregnancy. To reach younger generations, the One Heart team has also started a student awareness program to help disseminate information about safe pregnancies and birthing. 

“This is the first time I have closely observed OHW’s work and I have seen how their impact has been so incredible. The most important part is that OHW is working in rural municipalities where most organizations have failed to work or invest,” said Dr. Purusotam Raj Sedai, Senior Health Administrator of Health Office in Kavrepalanchok. 

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As the Senior Nursing Supervisor of Ilam District Hospital, Sabina S. and her small team of 15 nurses usually have a lot on their plates. As the main hub for healthcare services of the district, Ilam Hospital usually has a huge inflow of patients. The nurse-patient ratio is exceedingly high, with each nurse providing care of so many patients due to a big shortage of their medical workforce.

“It is challenging but we are not complaining as we have a dedicated team of nurses to provide quality services,” says senior nurse Sabina, who believes that the hospital can achieve a lot with better and adequate equipment, which is often a challenge for most of Nepal’s public hospitals that are low on resources to invest in upgrading their facilities.

One of the biggest challenges caused by resource constraints is also the lack of well-equipped neonatal care units in most public hospitals like Ilam Hospital. But there is now a positive development at the hospital, and all nurses are elated with the news of a new system in place that is making their dream of having a high-quality Special Neonatal Care Unit (SNCU) in place.

In March 2021, One Heart Worldwide (OHW) provided full support to bring in a complete set of quality equipment that is essential to creating a well-functioning neonatal care unit. They now have a set of radiant warmers to keep the babies warm and to prevent hypothermia (a dangerous drop in body temperature), syringe pumps, incubators, room thermometer, oxygen concentrator, mobile x-ray machine, and several other essential kits.

“All the new equipment will help to achieve our vision for creating a model SNCU and we all owe so much to OHW for making this happen,” says Sabina.

She recalls how the nurses used to provide neonatal care services in a small corner of the post-op room. Even after a separate room for SNCU was created, the hospital had been struggling to purchase equipment but had only managed to bring in a few machines.

“We had been demanding to create a special neonatal care unit so that we could also help families save their medical expenses while they were seeking intensive care in private hospitals outside the district,” explains Sabina.

Her hospital also had no choice but to refer the patients outside Ilam for special neonatal care during high-risk complications.

Even the private hospitals of Ilam district are not well-equipped to provide specialized neonatal care. Most of the families are often referred to B.P. Koirala Institute of Health Sciences (BPKHS) in Dharan sub-metropolitan city, nearly 150 km distance, and one of Nepal’s biggest and well-equipped hospitals. But usually, the SNCU is packed at the hospital and many also travel to nearby bordering Indian cities.

The journeys to other health and medical centers are long and often risky for the babies and their treatment will be delayed, and the families often end up spending a lot of money for travel, lodging, and medical treatment.

There is now a new hope in Ilam that neonatal care services will improve with the help of the newly equipped SNCU.

“We are confident that our hospital will be able to provide high-quality neonatal care and OHW’s support to equip our SNCU will definitely be impactful and benefit our communities both in the urban and rural municipalities,” says Ramanta Poudel, District Health Coordinator of Ilam district.

She shares how neonatal mortality is still high in Ilam. According to OHW’s own investigation findings, they recorded 35 cases of neonatal deaths in 2020. OHW team conducts validation following every neonatal death through its verification process. Most cases are related to premature births and underweight babies.

“The main reason for the neonatal risks is also due to lack of postnatal care (PNC) and that is a national problem. Most families that we have met believe that the babies will be fine after normal birth delivery at the birthing centers. They want to return home immediately after birth and when they return home, they practice their old traditions of taking care of their newborn babies,” says Sarita S., Public Health Nursing Officer of Ilam Hospital.Despite an increase in institutional birthing, OHW found many babies at high risk often caused by delays in reaching birthing centers. The team also found babies whose lungs were not properly functioning. Even in normal deliveries, there were cases of pneumonia, jaundice, and hypothermia. 

“Now, we have all the best equipment at the SNCU and will help our nursing team to do better diagnosis and can also provide better PNC counselling to the mothers This is why OHW’s support for our SNCU has been so significant,” explains Sarita.

For the local government in Ilam district, equipment support from OHW for the SNCU of the government hospital has been a huge relief, according to the local government body, District Coordination Committee (DCC), which plays a key role in local development budgeting, planning and coordinating the implementation of development initiatives.
“When OHW came to our district with its safe motherhood program, a lot of our burden was lifted by upgrading birthing centres in the rural municipalities. It has now helped us to equip our SNCU at the hospital and that will make a significant impact in our aim to promote maternal and neonatal health care in our district,” says Ilam DCC Chief, Ganesh B.

He shares how his office has a huge responsibility of generating their own internal resources as the budget allocation from the federal and provincial governments will not be enough to carry out all the development activities. Ilam is constantly faced with the challenges of financial resources as a huge chunk of the budget is allocated to road infrastructure, water supply, and new electricity poles in both urban and rural municipalities. Many districts often struggle to find resources to invest in upgrading maternal and neonatal care services. Now with the COVID19 situation, there will be an increasing challenge due to resource constraints.

“There are many government hospitals in many districts where the neonatal care units are still not well-equipped. Such support from OHW in Ilam district has been of immense help to run a high-quality SNCU,” says Dr. Taranath Pokhrel, Director of Family Welfare Division, Department of Health Services in Kathmandu.

He shares how the local stakeholders including the government and local communities are very thankful for OHW’s support and will contribute to improving neonatal health in Ilam.

“We are highly confident that this will be a huge change in the hospital to provide specialized neonatal care for the local community. I hope OHW will continue supporting us in our initiatives for improved MNH services in more districts,” says Dr. Taranath.

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Mahamai Health Post
Mahamai Health Post
For many years, Dev Bhakta K. and his fellow members of Mahamai Health Post’s Birthing Centre Renovation Committee struggled persistently to lobby for creating a birthing center. It had been nearly 18 years since the health post had been built but the local community still didn’t have a proper health facility for institutional birth delivery.

It was only in 2019, two years after a new municipality was formed as a local government body (following Nepal’s nationwide restructuring of the governance system in 2017) that they were able to convince the local government authorities to establish a birthing center. But they had no resources to buy quality equipment and facilities to run the center.

“We didn’t even have trained nurses. All women with pregnancy-related complications had to travel to Birtamod city (3 hours of drive) and they often had to borrow money or take high-interest loans to cover the expenses for transport, lodging, and medication. It was very frustrating for everyone including us,” says Dev, who is the chair of the Mahamai Health Post Renovation Committee in Mahamai ward of Mai Municipality.

It was also the same year when One Heart Worldwide (OHW) had just started its safe motherhood program in Ilam helping to renovate birthing centers. When Dev and his team heard of OHW’s partnership initiatives with the municipalities, they rushed to meet the Mai Municipality and OHW for support.

Once they gained all the information about the partnership process, they immediately started raising their own funds from their own pockets and didn’t want to wait for the formal documentation process.

“This was a very good opportunity and we didn’t want to wait for Mai Municipality to complete the process. We were confident that the office would pay later but we didn’t want to lose this golden opportunity to work with OHW,” explains Mahamai Ward-7 Chair, Ram Prasad L., who is also a member of the renovation committee.

Limbu put in his largest share of contribution and convinced other members to also contribute immediately. They were able to raise enough funds to contribute their 50% share in the partnership with OHW to start financing the renovation of the birthing center in their health post.

“Today, we are so proud to say that we have a high-quality birthing center and we are really very thankful to OHW for being our partner in our endeavours to improve maternity services for especially the poorest families,” says nurse Sushila G., who heads Mahamai Health Post.

The floors are all tiled making them easy to clean with water. The tin roofs have internal ceilings and the old walls look fresh with new paint. The medicine cabinets are well organized. There are now more quality maternity beds and baby cots. There is a nice counter where the nurses can receive their patients. There is also a separate room for antenatal (ANC) counseling where the mothers can have privacy while sharing any concerns with the nurse.

“The whole environment has changed in our birthing centre. I am confident that our maternal and neonatal care services will improve. It is so good always see how the families are so eager to come here and they are really happy with the transformation of our birthing centre,” says nurse Kopila K., who was trained as a Skilled Birth Attendant (SBA) with OHW’s support.

When Khadka first joined the health post two years ago, she was struggling to run the birthing center. She had to often borrow equipment from another health post, which is far from her station. As a newly trained nurse, she also was worried at first that the local community would not trust her and on top of that, the poor condition of the birthing center always frustrated her patients.

“I was worried that we would not have a proper birthing centre and it was affecting my work also. But this has changed a lot in a short time with support from OHW and Mai Municipality. We owe a lot also to our renovation committee for their commitment to making this happen,” explains Kopila.

There was a time when nurse Khadka had difficulty handling even two women who had come for birth deliveries at the same time. But now, she has no worries at all even if she had multiple patients as there is a nice room for the mother and her family to rest. She also has her own workstation and a separate room for counseling pregnant women and mothers.

“I feel so safe with sister Kopila as she is such a well-trained nurse. And also, it is so comforting to be here as this looks like a hospital, and much better than many private clinics in Kathmandu,” says Hima T., whose birth delivery is due soon.  

Hima and her family had migrated to Kathmandu to find a better life many years back due to hardship in her Chulachuli village. They had to return back home after the COVID19 hit hard in the capital city, Kathmandu. When she had left the village back then, most women didn’t even want to visit the health post due to the poor services and most families wanted the birth deliveries at home.

“Today, I can’t believe that this is the same health post with such a quality birthing centre as it has transformed so much. I really never expected such a change and we no longer have to worry about delivering in a health post anymore,” says Hima.

Hima is also happy to see how the culture of institutional birthing has been growing in the local community. She shares how the young women are especially more informed due to regular visits to the birthing center, where they also have a close relationship with nurse Kopila and others in the health post team.

“We still have much work left to do for strengthening our health post and the partnership with OHW was a very good start to motivate us to do more. It has given a new hope how local governments can achieve so many things through collaboration with civil society groups,” says Limbu.

As the chair of Mahamai ward, he was under a lot of pressure when the local community constantly complained about the poor services at the health post. Many were angry because the health post didn’t even have an ambulance and had no doctor to help them during pregnancy complications.

Now, he receives a lot of compliments from the community for his leadership in transforming the birthing center but Limbu tells them it was all a combined effort. His team’s next priority is to build a staff quarter attached to the birthing center to provide accommodation for the nurses.

“They travel far from their residence to reach the birthing centre and it becomes especially difficult for our nursing staff to travel at night. We have planned our budget and we will start building the quarter soon for them,” says Ram. 

Most birth deliveries often take place late at night or during the wee hours of the morning and nurse Kopila has to walk all the way from her current residence in another village ward. She has to walk all the way and cross the long bridge and becomes especially very difficult during the monsoon.

“I am glad I was posted in this village ward as there is a lot of enthusiasm and support to enhance our services. I want to especially thank OHW as I would never be skilled as I am today if it hadn’t supported us to renovate and equip our birthing center,” says nurse Kopila.

Birthing Centre Renovation Committee, Mahamai
Birthing Centre Renovation Committee, Mahamai
Nurse Kopila with her patient, Hima
Nurse Kopila with her patient, Hima
Mahamai Ward Chair, Ram Prasad L.
Mahamai Ward Chair, Ram Prasad L.

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One Heart Worldwide

Location: San Diego, California - USA
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Michaela Hayes
San Francisco, California United States
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