Motherhood in the Madhes

- High Court employee Amrita KC fulfilled her duties as a polling officer in Nepalganj on election day, with her six-month-old daughter held in her arms. 

- The same morning in Kathmandu-1, RSP candidate Ranju Neupane appeared at the polling station to cast her vote with her 10-day-old baby. The next day, she became the first candidate declared a winner by the Election Commission.

Her party won a supermajority and will now be tasked with reforms in governance, development, the economy, and service delivery. At least four of the winning RSP candidates are doctors, and the party must fulfil its campaign promise of improving healthcare access across Nepal.

Among the lowest-ranking region for healthcare indicators in Nepal is Madhes Province.

Across the districts of Madhes and Karnali, where maternal and neonatal health outcomes remain poorer than in the rest of the nation, local governments in collaboration with non-profits, have financed and facilitated the operation of birthing centres where nurses are lifelines for pregnant women, new mothers, and newborn babies. 

At the Inarwari birthing centre in Rautahat district, nurse midwife Manisha Kushwaha gently applies ultrasound gel on the abdomen of 28-year-old Robina Khatun who is having a sonogram in the first trimester. 

Kushwaha glides the transducer over Khatun’s belly before pronouncing her baby healthy. She will later send the ultrasound machine for the municipality’s monthly mobile sonogram program in a neighbouring village. 

Ministry of Health and Population guidelines recommend that pregnant people make eight antenatal care (ANC) visits to health posts before their delivery date. Expecting mothers are also provided Rs800 for the eight visits and travel costs according to geographical region.

In Baudhimai, the local government provides more incentives: 10 eggs for non-vegetarian and protein powder for vegetarian mothers-to-be per visit. The municipality also provides free ambulance service for pregnant women, and conducts a monthly mobile sonogram program across all communities. 

The initiatives of local governments, health officials, non-profits, and volunteers have meant that institutional deliveries here have increased drastically. In Rautahat, institutional deliveries have increased from 50% to 68% in four years, according to figures from the non-profit One Heart Worldwide that works to improve maternal and neonatal health outcomes arcoss Nepal.

“Home deliveries have completely stopped in Inarwari, and women are increasingly accessing ante-natal and post-natal care, as well as family planning measures,” says Manisha Kushwaha. “Women and families here are now more aware of maternal and neonatal healthcare.”

One of them is Noor Jahan Khatun, who had her first baby at home and gave birth to her second child at the local birthing centre despite wanting another home birth. When the due date for her third child came around, she walked to the health post herself. 

“I realised it is much better to give birth at the hospital,” Noor, who is pregnant with her fourth child, told us. “They have everything we need in case of complications.”

The nursing staff at the birthing centre, as well as other centres in the municipality also periodically review their training in the birthing simulation room set up on the premises of the Inarwari birthing centre so that they retain their training and continue to hone their skills.

Over in Sarlahi’s Sundarpur in Chakraghatta Rural Municipality, a state-of-the-art birthing centre now stands adjacent to the derelict old structure from which nurses previously had to provide services. 

The new and improved maternity ward was built last year with Rs2.4 million from the municipality and a Rs2 million from One Heart Worldwide under a cost-sharing public-private partnership formula. 

Chief nurse Sunita Rai has been stationed here for the last six years, and looks at the old building. “I remember when we had to deliver babies while ankle-deep in flood water during monsoon,” recalls Rai. “This new facility and the equipment have improved service.” 

Since the start of the fiscal year, the six-nurse team at Sundarpur has delivered more than 140 babies. One day last month, a national holiday, the centre was quieter than usual, with just two women waiting for delivery. 

But fewer-than-usual patients does not mean there is no work to be done. In the afternoon, nurses make the rounds of the community to conduct post-natal care visits, and to keep track of how the new mothers and babies in the village are doing. This is important because neonatal mortality of babies within the first month of birth is still high.

“For the people in this village we are both the doctor and the nurse,” Rai says matter-of-factly as she walks towards the village to see a new mother.

In Sarlahi's Laxmipur Kodraha, Kanchan Rai makes her own rounds, calling out to several young children playing in the pale afternoon sun. Rai has been stationed in Laxmipur for 10 years and delivered most of those children playing outside herself.

A beloved member of the community, Rai is greeted by several women and invited in for tea and snacks as she walks by. The Laxmipur birthing centre has seen major renovations to make it more spacious, better equipped, and hygienic. Mothers now have more privacy, especially from men who in the past would simply barge in wanting to know which woman from the village was about to give birth. 

“We deliver 400 babies on average every year,” Rai says. “There have been zero home births in this village for the last five years, and women are increasingly accessing maternal healthcare and family planning services.”

Institutional deliveries in Sarlahi have gone up from 37% to 71% over the past five years.

Pregnant women who require C-sections, or those who experience complications during pregnancies, are referred to the nearest provincial hospitals in Gaur or Malangwa.

“Community-based awareness programs about going for hospital visits have helped reduce home deliveries, and counselling sessions provided to new mothers at provincial hospitals have contributed to better maternal and neonatal health outcomes,” says Sachin Yadav, obstetrician-gynaecologist at Malangwa Provincial Hospital.

SAFE MOTHERHOOD

Newborns with birth asphyxia, tachycardia, meconium aspiration syndrome and other complications are admitted to the special newborn care unit at the Gaur Provincial Hospital. But Apsana Khatun, chief nurse at the hospital’s maternal and neonatal unit says: “We have not been able to provide neo-natal care as effectively because we do not have an NICU.” 

Provincial hospitals provide life-saving services, but remain underfunded and in need of life-saving equipment.

At the Gaur Hospital, Rukmini Kumari Shah gently rocks her three-day-old son, who was admitted to the special newborn care unit due to birth asphyxia and dehydration. 

“I have not even been able to think of a name for him,” says the 25-year-old. “My other two children were born normal but I worry for this one.”

This is where the election pledge of the RSP will be tested. Will the new government cut through the bureaucracy, corruption and resource constraints to provide life-saving services to mothers and babies in places like Rautahat and Sarlahi?

There has been no maternal mortality at the Malangwa Provincial Hospital for the last two years, but the hospital has had neonatal deaths.

“We need more spacious waiting areas and training for maternal and neonatal healthcare workers,” says Sachin Yadav. “Without that we are unable to serve our patients and have to send them to Kathmandu or Birganj.”

In Baudhimai village, patient numbers have increased by 140% in the last three years, but the federal government slashed the health budget by 60%. The government across three levels is supposed to provide 98 types of essential medicine free of cost at primary healthcare centres, but the federal and provincial governments often fail to make their share of the drugs available. 

“Federal and especially provincial governments have been irresponsible when it comes to investing in local healthcare,” says Baudhimai mayor Pradeep Kumar Yadav. Health workers and institutions continue to work without being paid or funded when the budget remains frozen for months at a time. “It does not matter to a patient when the fiscal year begins,” says Sachin Yadav at the Malangwa Provincial Hospital. “Maternal deaths do not wait for the budget to be released.”

And despite budget constraints, political posturing still continues. At local levels, officials build multiple birthing centres in each ward when one would suffice, and these buildings remain empty. 

Politics also plays a significant role in whether or not local officials are willing to agree when health officials try to refer pregnancy-related complications to better-equipped facilities.

And while services have improved due to the efforts of dedicated healthcare officials, they are transferred from one place to another at the whim of governments that come and go, which means staff turnover in these institutions is very high, affecting consistent service delivery.  

Yadav has been at Malangwa for three years— during which yearly institutional deliveries have gone from 2,000 to 3,200 and C-section births have gone from 150 to 700. He had just begun to hit his stride at the hospital when he received transfer letters to another hospital. 

So far, he has managed to hold on to his position in Malangwa, but he does not know how long he will be able to delay the transfer.   

Tackling patriarchy

Nepal has made dramatic progress in reducing the maternal mortality rate (MMR) from 539 per 100,000 births to 142 over the past 30 years. But that is the national average. MMR is still high in parts of Nepal where access to healthcare and adoption of health services are not as extensive.

One reason is that despite birthing centres and awareness of pre- and post-natal healthcare, socio-cultural norms in a patriarchal society also mean that female literacy remains low, and the rate of underage marriage is high. 

Rautahat has the lowest literacy rate in Nepal, and the lowest female literacy rate. This has a direct correlation with its its fertility and maternal mortality rates. Gaur Hospital continues to see maternal and intrauterine fetal death (IUFD) deaths due to a lack of ANC visits by patients.

In the absence of education and information, socio-cultural misconceptions still persist. Women refuse to take essential pre-natal medication like folic acid because they think it will affect their babies’ complexion, and do not eat enough fruits because they believe it will cause fetal pneumonia. 

Women are also expected to get through their pregnancies without going for health check ups in keeping with the tradition of their mothers and mothers-in-law enduring pregnancy and childbirth at home without access to healthcare.

Maternal and neonatal health outcomes are also affected by child marriage, as well as the patriarchy-enforced preference of a male child in the family. 

At Gaur Provincial Hospital, 25-year-old Asha Kumari stands with her hands braced against the hospital bed as she is gripped by a contraction. Her eldest child is already 12, and she is at the hospital to have her fifth baby. 

“She had already had two children by the time she was 18,” explains her mother, who is here with Asha’s mother-in-law.  

Officials worry that reporting instances of child marriage might mean that women no longer trust health workers and hospitals, and stop accessing healthcare altogether. They insist that investment in maternal health needs to be accompanied by socio-cultural interventions.