Every day approximately 800 women die across the world from preventable causes related to pregnancy and childbirth. These lost lives are not just a number, but they are a mother to a child, a wife to a husband, an aunt to nieces, and much more. The loss of the life of one woman, which is easily preventable, is a societal loss. The lost lives of tens of thousands each year in countries around the world must prompt a serious discussion on improving maternal health across the economic development spectrum of nations (Mackay, 2006). This past year, Globemed at Tufts has worked with Nyaya Health to fundraise money to alleviate any resource burden that pregnant mothers might face to access their right for antenatal care and delivery in Achham, Nepal. As we look forward to our new partnership with PHASE Nepal and its initiatives, we reflect on the endemic structural problems which present barriers to mothers accessing antenatal care and health-facility based delivery.
Complications through pregnancy periods can easily endanger the mothers’ and the child’s health and depend heavily on timely management and treatment. During pregnancy, the World Health Organization recommends at least four antenatal visits, which include tests to ensure the mother’s health as well as the fetus’s. However, the major causes of maternal mortality are complications during birth itself, such as hemorrhaging, infection, high blood pressure, unsafe abortion, and obstructed labor.Institutional birth with trained and certified attendants at birth such as obstetricians, family medicine physicians and certified midwives, was a prominent factor in the decrease in the world maternal mortality rate between 1990 and 2010, during which, maternal mortality worldwide dropped by almost 50%.
Certain areas of the world have disproportionate encumbrance of maternal mortality: the burden of this mortality falls almost entirely upon the world’s poor, as 99% of maternal deaths take place in low-income countries (World Health Organization). Nepal’s government has recognized this fact and is working to implement a comprehensive strategy to reduce maternal health. In Nepal, a skilled birth attendant is present at a mere 36% of births (Kaiser Family Foundation, 2012), far below the recommended level. Demand for skilled birth attendants is high, but the actual supply of such individuals cannot meet the demand (UNICEF 2013). The major problem is funding: training future skilled healthcare workers requires a high investment, as does creating new facilities and supporting existing ones. However, a strong political focus on this goal, along with “sustained financial commitment from government and donors” over the past few years (Engel, 2013), has resulted in an increased number of skilled health workers along with improvement in access and quality of facilities.
The government’s attempts to improve maternal health resonate deeply at Nyaya Health, located in rural far western Nepal and Globemed at Tuft’s partner from 2010-2013. In the Achham district where Nyaya serves the population with free clinical care from Bayalpata Hospital, the best estimate of maternal mortality offered by delivery facilities is 800 deaths per 100,000 live births, a figure which is most likely an underestimate due to limited data collection among mothers and births occurring outside an institutional setting (Schwarz, 2013). This staggering figure dwarfs Nepal’s maternal health statistics as a whole, and is a result from the geography and other structural factors.
Achham, as one of the most underdeveloped regions of Nepal, exemplifies many of the problems of delivering care to a remote region. In Achham, villages and healthcare centers are often separated by mountains paved with roads with one lane each way; some poorly maintained and all treacherous in poor weather conditions. For most Achhamis, accessing clinical health care means walking, sometimes for hours. Pregnant women late in their pregnancy are unable to make the journey unassisted. Some of them are able to access buses or private motor vehicle transports, while others are reliant on stretchers carried by family or friends to bring them to the hospital. In both cases, the journey serves as a major disruption to the workday of both the mother and her immediate social network, which can be difficult for families who may feel that they do not have the resources to commit to an institutional delivery or regular antenatal care. This is not just a question of financial resources, but also social resources. This is especially important for the many migrant families in Achham, as many women who deliver while their husband is working abroad report having insufficient social capital to assist them in making the trip to the hospital (Nyaya 2013).
While there is still a lack of understanding about healthcare facilities and services available, awareness and health education is much better in Achham than it was four or five years ago, made possible by the Nepalese government’s efforts and also to the efforts of Nyaya Health. The government’s female community health volunteers (FCHVs), along with Nyaya’s Community Health Worker Leaders (CHWLs) are an integral part of providing primary healthcare services and raising awareness in Achham. More Achhamis than ever before are utilizing services such as the local government-run Health Posts and sub Health Posts, as well as Bayalpata Hospital’s services. However, maternal health offers a unique challenge. Most outpatients coming in to Bayalpata come for a specific issue or complaint which is often treated that day or with one follow-up treatment and then do not return. The four recommended repeat antenatal visits is a difficult commitment to make, because of the time commitment it takes. This is shown in Nyaya’s clinical data (Nyaya 2013).
For every four mothers coming in for one antenatal visit, only one of them continued all the way to the fourth visit. In addition, there were almost 2.5 times as many institutional deliveries as fourth antenatal visits. These findings could have a few interpretations. Firstly, it is possible that while people understand the general principle behind antenatal visits, the difficulties of accessing repeat visits combined with a lack of immediate effect result in fewer people coming to repeat antenatal visits. On the other hand, a heavy educational emphasis by community health workers on the importance of institutional deliveries, combined with more visible and immediate benefits of having an institutional delivery as opposed to a delivery at home, may mean that many mothers who didn’t attend all four antenatal visits or any at all choose to deliver at the hospital because they recognize its importance. Another possible interpretation is related to the way Nepal’s incentives work regarding maternal health. In addition to training more healthcare workers, the Nepalese government offers individual incentives to mothers for antenatal visits is 100 rupees a visit, a not insubstantial sum in Achham, while deliveries are incentivized by 1000 rupees. For Achhami women weighing the costs and benefits of both delivering and receiving antenatal care, the onetime 1000 rupee incentive may make an institutional delivery much more attractive, while the 100 rupee incentive for antenatal care may not be enough for Achhami women to decide to receive antenatal care.
Despite efforts by the Nepali government and NGOs such as Nyaya Health and PHASE Nepal, maternal mortality remains high. In the end, it is up to the government, possibly in partnership with non-governmental organizations such as Globemed at Tufts’ partner, to design and implement a system to make sure all expectant mothers get the care that they deserve before, during, and after delivery. The path to achieving safe motherhood for all is arduous, but like most public health initiatives, it is worth taking. Nyaya Health, PHASE Nepal, and other organizations, in partnership with engaged citizenry and students such as those at Globemed at Tufts, remain committed to the challenge ahead.
Engel, J. (2013, ). A paradigm shift for maternal health in nepal . The Overseas Development Institute
Mackay, A., Berg, C., King, J., Duran, C., & Chang, J. (2006). Pregnancy-related mortality among women with multifetal pregnancies. Obstet Gynecol, 107(3), 563-568.
Nyaya Health. (2014). Monthly data reports. Retrieved 02/23, 2014, fromhttps://www.dropbox.com/s/tusngngjmnvcz81
Schwarz, D. (2013). Maternal outcomes. Retrieved 02/23, 2014, fromhttp://wiki.nyayahealth.org/w/page/4682710/Maternal_Outcomes
The Henry J. Kaiser Family Foundation. (2013). Births attended by skilled health personnel (percent of births). Retrieved 02/23, 2014, from http://kff.org/global-indicator/births-attended-by-skilled-health-personnel/
UNICEF. (2013). Statistics on nepal. Retrieved 02/23, 2014, fromhttp://www.unicef.org/infobycountry/nepal_nepal_statistics.html
World Health Organization. (2012). Maternal mortality: Fact sheet. Retrieved 02/23, 2014, fromhttp://www.who.int/mediacentre/factsheets/fs348/en/