Be BIJAY GAJMER
Early marriage and lack of nutritious food are the reasons for premature deliveries in rural Nepal. Poorly equipped hospitals and poverty add to their difficulties.
The incident
Seventeen-year-old Kisim Chaudhary and his in-laws knew that his newborn would die if he were not immediately taken to a better hospital. But they still wanted to go home. They simply did not have enough money to take her to the sub-health post-hospital where Kisim had delivered the baby.
“The family is impoverished and could not afford to take the baby to a hospital where he could be treated,” said Pushpa Sigdel, an auxiliary nurse midwife at the sub-health post, who took Kisim to Dhodari in Bardiya. Kisim had married when she was 15 years old. At 16, she had a miscarriage, and at 17 she conceived again.
Sigdel, who delivered the baby, explained that Kisim had a premature birth and the baby was underweight. He had to remain under observation for at least six hours. But other than that, the family didn’t have the means to save the baby.
In Kisim’s case, the family could not afford the Rs 2,100 to hire an ambulance. They had no money beyond the Rs 500 provided by the government to have a child at a designated birth center. Kisim’s husband has been working as a construction worker in Shimla, India, for six months and hasn’t contacted the family.
Knowing full well that the baby would die if taken home, the family always opted not to go to the Nepalgunj Zonal Hospital because they did not have the money to do so. Instead, they were ready to take the child home in the ladiya (bull cart).
However, Sudarshan Shrestha, director of media and communications at Save the Children, came to their rescue. He asked Sigdel if the baby would survive after being taken to the hospital. She said anything could happen as the baby was not breastfeeding and only had a spoonful of milk.
“The family was so poor that they had no choice but to let fate take its course,” says Shrestha, adding that he decided to finance the initial expenses and then seek help for the family.
After Shrestha volunteered to bear all the expenses, the baby was taken to Bheri Zonal Hospital in Nepalgunj. Before going to the hospital, he called them to make sure they had a ventilator. The hospital confirmed they had and also said they could accept the baby.
But at the hospital, doctors tried to pump oxygen manually in the emergency room and said they didn’t have ventilators. They also noted that Nepalgunj Medical College was the only hospital in the area with ventilators. Doctors advised that the baby should be cared for there without further delay.
The baby was rushed to Nepalgunj Medical College, which was just a few minutes away from the local hospital. At the medical college, the hospital authorities informed the family that the baby would have to stay on the ventilator for five days, after which he would be shifted to the Neonatal Intensive Care Unit (NICU).
“We agreed to do as advised because it meant the baby would survive,” Shrestha said.
It would cost Rs 5,000 per day for the baby to be kept on the ventilator. Shrestha paid the bill for that day. The medicines have been purchased. It finally looked like the baby would survive. But on March 30, 2014, the baby died at two in the morning. It was just 12 hours after the birth.
A source who did not want to be named later confessed that the ventilator at the hospital was not working, although they were trying to get it repaired. Kisim’s father-in-law, Radhe Kisan Chaudhary, was made to pump the oxygen manually with the bag and mask.
“I didn’t know how to use the bag and mask and couldn’t do it properly. The hospital didn’t put the baby on the ventilator at all,” said the visibly upset elderly man.
The hospital, even after charging for the ventilator, could not provide the facility and the baby died without the necessary treatment to survive.
The reasons
Kisim’s case is not unique. Almost all households in rural areas, especially in the Far West region, have had a woman delivered prematurely or have a miscarriage.
On April 3, 2014, Parbati Chaudhary, 25, of Magarwadi VDC in Bardiya lost her 22-day-old baby. She also had a premature birth, and her baby weighed just over two pounds at the time of birth.
The baby’s health was improving, but suddenly he showed signs of some respiratory problems and developed a fever. The child died on the way to the hospital. It was Parbati’s sixth child who died. Previously, four babies had not survived more than two days each, and the other she had miscarried. Parbati was 16 when she got married and has been conceiving almost every year since then.
In rural areas, the main reasons for premature births are that most mothers are young, and because of extreme poverty, nutritional needs are not met. Early marriage is still prevalent and many, if not all, are unaware of reproductive health issues. Miscarriages are also quite common among women in rural areas, and most miscarriages occur when there is no spacing between pregnancies or conceiving immediately after a miscarriage. Nutritionist Nira Sharma, who is based in Nepalgunj, says most premature births and miscarriages are due to nutritional deficiencies. The iron pills that the government provides at health posts during pregnancy are not enough. Backing up his statement is Dr. Aruna Uprety, who says a regular protein diet is equally important. According to her, the government only distributes iron pills to women during pregnancy and nothing has been done to ensure that their dietary needs are met.
“Lack of good nutrition is the main reason behind the delivery of underweight and premature babies,” she adds, explaining that if a woman does not receive good nutrition, and the baby is born healthy, there is a good chance that he will suffer from kidney problems. Future problems and brain development will also be slow. However, families cannot afford nutritious food all year round, leading to several deficiencies among women, resulting in pregnant mothers having miscarriages, babies being born prematurely, and/or suffering from respiratory problems after birth. “Nutritious foods during pregnancy are important, but good nutrition during the pre-pregnancy phase also makes a huge difference in maternal and child health,” says Sharma, explaining that it is difficult to manage even two full meals a day for many families in rural areas. In most villages, another reason behind the high mortality rate among children under five is pneumonia because the baby is not treated properly. Another reason for infant mortality is hygiene. “In some places, social taboos like covering the baby entirely in old clothes can result in the baby getting pneumonia and infections that can cause death,” says Dr. Uprety. Apart from threats of early marriage, and lack of good nutrition and hygiene affecting the health of mothers and their babies, the fact that health posts and even hospitals in rural areas are not well-equipped adds to the seriousness of the situation. Hospitals lack qualified staff, working equipment, and adequate facilities. Dr Uprety adds that in the case of premature births and underweight babies, even many hospitals in Kathmandu are not well-equipped to handle these sensitive issues. And the problem is even worse in remote areas, especially in the western and far-western parts of Nepal.
Government Initiatives
The government has taken certain measures to ensure safe childbirth and reduce infant and maternal mortality. A pregnant woman who attends all required regular check-ups and delivers at the designated birth center is provided Rs 500 in the Tarai, Rs 1,000 in hilly areas, and Rs 1,500 in mountainous areas as travel incentives. The government also gives nyano jhola which is believed to have helped reduce the infant mortality rate. The kit has a pair of bhoto and daura, gloves and socks, a hat, a towel and wraps for a baby, and a dress for the mother to use while breastfeeding. This program covers all 75 districts, but only babies born in district hospitals and community delivery centers are eligible for nyano jhola. After government encouragement, many pregnant women now go for regular checkups and have their babies in the presence of trained personnel to carry out the deliveries.
However, according to the Demographic Health Survey (Nepal) 2011, 35% of births happen in health facilities, while 63% are still at home. According to Dr Shyam Raj Uprety, director of the Child Health Division at the Ministry of Health, the government is trying to improve immunization and ways to prevent pneumonia to reduce the child mortality rate in rural areas in the future. “We are aware of the health issues that women and newborns face, and we will make it our priority to address them,” says Dr. Uprety, explaining that iron pills will also be distributed to school-age girls to tackle iron deficiency problems. “WHO and UNICEF have jointly developed a strategy called Integrated Management of Childhood Illness (IMCI) to reduce the child mortality rate, and we are also planning to implement this program,” adds Dr Uprety. IMCI is an integrated approach to child health that focuses on child well-being. It aims to reduce mortality, disease, and disability and promote improved growth and development in children under five. It includes preventive and curative aspects that families, communities, and health facilities can implement. Where is he? Around 600,000 women give birth each year in the country, with half of births taking place in district hospitals and community birthing centers.
According to Nepal Demographic Health Survey 2011, more than 20,000 newborns die every year. Nevertheless, according to Central Bureau of Statistics and UNDP documents, Nepal has significantly achieved the Millennium Development Goal (MDG)-4 by reducing child mortality by more than half before the 2015 deadline. Until 1990, the under-five mortality rate per 1,000 live births was 162. The figure fell to 54 in 2013. But this is the national record, and the main contribution to this figure comes from the cities with high populations. The infant mortality rate in the Far West is still 86. The problems of premature births and infant mortality have many roots, not just one factor, but rather a combination of factors. Nutritional deficiencies, early marriage, poverty, and lack of proper facilities in hospitals are some aspects that need to be addressed and addressed now.
The government has made progress, but much more needs to be done before cases like Kisim’s can be addressed or even avoided turning tragedy into wisdom, from giving birth at home to encouraging other mothers to choose safe delivery at designated birthing centers. Pushpa Sigdel, 40, from Bardiya was 15 when she got married. A year later, she gave birth to a baby girl. But the birth was not easy. Women in the villages had to rely on traditional birth attendants rather than trained health workers, which meant that no medical help was available, making the birthing process extremely difficult and risky. Apart from delivering her baby at home, Pushpa also suffered from uterine prolapse. “At that time, there were no health facilities,” says Pushpa, adding that she considers herself lucky to be alive. Pushpa’s story doesn’t end there. In 2001, she had the opportunity to participate in an 18-month training program in Dhangadi to become an Auxiliary Nurse (ANM). After completing the government-funded program, she was lucky to work at the Dhodari sub-health post in Bardiya. She has worked there since 2006. “I didn’t want other women to suffer the same difficulties as me, and to help women, I wanted to be a health worker,” she says. Pushpa has had many successful deliveries during her career, but not all cases have been easy. Since the health substation where she works is not well-equipped, she has to refer many pregnant women to Nepalgunj Zonal Hospital when they show signs of complications. “Many families are so poor that they cannot afford to go to the regional hospital,” she says, adding that although they can save the baby by taking the mother to the hospital, they choose to return home because they do not have the money to pay for medical expenses.
According to Pushpa, it is not that women in rural areas are not aware of what needs to be done during and after pregnancy, but their financial situation is not good enough to meet their needs. “When pregnant women come for check-ups, they are told they need to eat nutritious foods, which include pulses and meat. They are also told not to lift heavy weights,” she adds, explaining that they even go so far as to tell women and their families to start organizing funds in case of a medical emergency. Even though Pushpa is dedicated to helping other women, she has to deal with too many constraints due to the lack of facilities at the health substation. It has limited equipment and facilities. Load shedding is another important problem. She has to rely on candlelight when the cases come in the evening. “I think women would not have to go to regional hospitals, even in complicated situations, if the secondary health post had all the necessary facilities and more trained staff,” she said, expressing the need. I hope the government provides more facilities so that she and other ANMs like her can help save the lives of pregnant mothers and their newborns.
Bijay.gajmer@gmail.com
