Ensure Safe Motherhood for Women in Rural Nepal

I will never forget what happened in Sankhuwasabha, a district in eastern Nepal. Known for the world’s deepest valley – the Arun Valley – and cardamom farming, it is one of the most remote places that One Heart World-Wide (OHW) serves. It is also the place where I realized what keeps me motivated to work in the field of maternal and neonatal health (MNH).

As a Clinical Program Officer for OHW, I was in Sankhuwasabha to conduct a three-day training on MNH. Our team consisted of a Public Health Nurse, a representative of the District Health Office, the OHW District Coordinator, and the staff of Tumlingtar Health Post (HP) and birthing center. Together, we also conducted a needs assessment for the HP, to find out what kind of supplies and equipment were still needed.

As we spoke with the medical staff of the HP following the needs assessment, an aging woman rushed towards us. “My daughter-in-law is in critical condition,” she spluttered. “She is very weak. Please help us!”

It was around 2:30 in the afternoon. Our attention was captured by the exasperated voices of a crowd, quickly approaching the HP. They were carrying a stretcher.

The woman on the stretcher was on the verge of losing consciousness. Wearing a red gown, and a red scarf around her head, she hummed indistinctly with her eyes shut. Her skin felt cold.

The young mother, Bhim, was 18, and had given birth earlier that day, at 11 AM. Her 19-year-old husband, holding their newborn baby, told us that her condition had worsened after giving birth. The baby’s umbilical cord was still attached to the placenta, which had not been delivered after the baby was born. For three hours, the villagers had waited for the baby’s cord and retainedplacenta to come out.

I was very disheartened to see that a rusty metal hoe, commonly used for ploughing fields in rural Nepal, was hanging between her legs.

“One of the elderly women in the village asserted that a weight tied to the cord will bring the placenta out,” her husband said. “We made her walk for a few minutes. She grew weaker."

Our examination found that the young mother's blood pressure was 110/50, her pulse was 120 beats/minute, and her respiration rate was 22 breaths/minute. This meant that she was going into shock. Her vital signs had to be stabilized before we could address the retained placenta. We did not have much time.

While the Public Health Nurse took the lead on stabilizing her vital signs, it was an opportunity for me to instruct the HP staff and MNH training participants on how cases of retained placenta should be managed.

The young patient was given an injection of oxytocin intramuscularly, her bladder was emptied of urine by performing catheterization, IVs were inserted into both hands (a plain saline drip in the right hand and a drip with oxytocin in the left hand), and she was given an injection of Ampicillin for prophylaxis. Finally, a blood examination was done to know the status of her hemoglobin level. She was in stable condition. The next step was to employ the safest measure to remove the placenta.

After the patient was stabilized, a skilled birth attendant (SBA) from Tumlingtar HP performed active management of the third stage of labor to stimulate the uterus to expel the placenta. The attempt was unsuccessful. At around 3:15 PM, the Public Health Nurse (who is also a trained SBA) decided to perform a manual removal of the placenta, which was successful. The patient also had a second-degree perineal tear, which was sutured by trained nursing staff from the HP.

The young mother recovered quite well. Through a combination of skilled personnel on duty, basic equipment and swift management, we were able to save the life of this young mother, who might have otherwise met with tragedy if we were not at the right place, at the right time.

“I don’t know if I would have survived to look after my son if it were not for all of you,” she said, expressing her gratitude. “I cannot be thankful enough.”

As a mother of two daughters, both older than her, I felt happy for being able to save this innocent mother, but at the same time I felt bad about the overall situation of Nepali women in remote areas, who marry and become mothers at such young ages.

OHW began working in Sankhuwasabha in 2017, and is actively implementing the Network of Safety model in the district. This is the most resource-intensive phase. The major focus for the next three years will be to implement training programs and facility upgrade activities. Medical providers will be trained to become SBAs, and continuing medical education will be provided to existing SBAs. Female community health volunteers and community health workers will be trained to become community outreach providers, and local stakeholders will be trained in birthing center management and program collaboration. Health facilities will be upgraded into fully functioning, government-certified birthing centers. OHW’s mission to combat maternal and neonatal mortality and morbidity is advancing through our work in this remote district.

Later, back at my hotel in Kathmandu, I was lost in contemplation of everything that had unfolded during this trip. I wondered what would have happened if that young woman had been half an hour late, if our team of skilled health workers was not present, or if her case was referred elsewhere. I remembered the look of relief and happiness on her face after we performed the life-saving procedure, and her words of gratitude. My encounter with her made me proud to be working with OHW to save the lives mothers and newborns in some of the most challenging locations on Earth.

Just before leaving Tumlingtar HP, I looked back and saw the young couple sharing a tender moment with their newborn baby. That moment will be forever etched in my memory.