Womens Health in Nepal
Tuesday, August 24th, 2010I wish someone had taken a picture of my facial expression on my first day at the Women’s Hospital in Kathmandu; I could have sold it to the Tate Modern entitled ‘Horror: Epitomised’. What had tickled my ‘shock’ node so intensely was the realisation that in this cramped, dark, and humid cattle pen crammed with hundreds of waiting women, were doctors peeling off their intimate examination gloves into a scum encrusted bucket, ready for re-use. Later, it transpired that these gloves were transported to a place of hygiene safety whereupon they were sterilised for the next patient. Similarly, theatre drapes, gauze and instruments were scrubbed in the courtyard and line-hung to dry. The ‘single use only’ mentality is so deeply inculcated in the medical fibres of my being that I experienced a knee-jerk feeling of disgust. However, it led me to reflect on the concept of sterility, cost of running and the relation to overall healthcare provision in both the UK and Nepal.
Many consider access to safe childbirth and women’s health a basic human right. The 1996 Nepal family health survey found a maternal mortality rate of 539 out of 100,000 live births and a neonatal mortality of 39 in 1000 live births (1). Why such a poor track record for mortality?
A recent Nepali article highlighted one of the most important causes of neonatal mortality is a high incidence of home births with no trained attendees. Nearly 90% of Nepali women give birth at home. Poor antenatal care is a critical factor, and half of Nepal’s child-bearing women still receive no antenatal care (2). Partly to blame are logistics: poor infrastructure and large hills which make travelling to clinics in rural areas unfeasible. We witnessed this first hand when trekking through the Annapurna circuit. To travel from one settlement to another requires enough people to make the ‘bus’ journey viable. No fewer than 25 people must cram onto a jeep to enable the locals to travel along a slippery ravine-edge to the next town. Whilst myself and a friend clutched each other for dear life, a woman in the front had commenced labour and was being escorted by her family to the nearest hospital. It quickly became apparent that she would not make it in time and would have to find a house in the next town to give birth.

Unsafe abortions account for one third of all maternal deaths in some parts of the world. Deaths from the complications of abortions are largely preventable with adequate access to family planning information and the provision of safe abortion care (1). Nepal took strides towards safeguarding women’s health by legalising abortion in 2002. Compared to neighbouring countries, such as Pakistan where abortion is illegal, Nepal is commendable for its provision of free and safe abortion care (3). Our first day visiting Nepal’s Women and Children Hospital was spent taking part in a training day for the Family Planning Association of Pakistan (FPAP) (4) to enhance their pre, intra and post abortion care skills. Abortion is only permitted in Pakistan to save the life of the woman, and to preserve physical and mental health. Despite this, the FPAP were obliged to take training outside of their country due to religious hegemony surrounding the issue of abortion.
Nepal is admirable in that, despite being one of the poorest countries in the world, the government and other stakeholders have been proactive for policy change. Several bodies have been set up, such as the Safe Motherhood Programme under the Directorate of Health Services of the Ministry of Health’s guidance (5). The aim of this programme was to reduce maternal and neonatal mortality by advocacy and media strategy as well as more practical interventions such as cord blood banking and improved access to skilled birth attendants. In concordance with the Second Long-term Health Plan of 1997-2017, Nepal intends to reduce the Maternal Mortality Rate (MMR) to 250 by 2017.
Upon analysis, Nepal compares favourably with countries of similar Gross Domestic Products (GDP). Afghanistan, for example, has a MMR six times as high. In comparison, South Africa has a GDP seven times that of Nepal, yet has a comparable MMR. The aspiration to reduce MMR in Nepal to 250 brings it on a par with India’s ratio, which boasts a GDP more than double that of Nepal.
Despite bring a poor country, the Government of Nepal, aided by the Indian Government, have provided free hospital healthcare to the poorest members of society at Bir Hospital since 1889. There was a trained midwife present from 1920 onwards, and obstetrics and gynaecology moved to Prasuti Griha hospital in 1985 for more space. From humble beginnings, the hospital now has 321 beds and provides outpatient services as varied as colposcopy, comprehensive abortion care, family planning services and sub-fertility clinics and is the tertiary referral centre for women in the country. The majority of these services are entirely free, with no additional basic healthcare perks reserved for privately paying patients. The atmosphere of the hospital is that of adequate provision of healthcare staff, with a greater emphasis on nurses running the wards. The overall impression was that of efficiency in terms of cost in order to afford the skilled healthcare professionals needed.
This led me to question the financial and material wastefulness of the western world. At Prasuti Griha, adequate care is provided to as many people as possible, within the context of limited resources. This is an echoing theme throughout the corridors of the world’s hospitals, irrespective of a country’s prosperity. Despite all this, if I were faced with an internal examination at Prasuti Griha compared to the shiny Norwegian International Hospital across the road, I know which I would choose.
Sian Cooper
Barts and the London Medical School
siancooper1(a)gmail.com
1. Status of maternal health in Nepal. Vaidya, Achala.
2. A glimpse on the maternal, child health and family planning in Nepal. Giri, Kanti. s.l. : N. J. Obstet. Gynaecol Vol. 1, No. 1, p. 76 – 79 May 2006.
3. Publications – Abortion. [Online] [Cited: 29th July 2010.] www.un.org/esa/population/publications/abortion/doc/pakistan.doc.
4. Association, Family Planning. [Online] 2010. www.fpapak.org/.
5. Motherhood, Safe. http://www.safemotherhood.org/. [Online] 29th July 2010. http://www.safemotherhood.org.np/pages/default.php?function=content_ssmp&secid=35.
6. World, Gapminder. gapminder.org/world. [Online] 2008. [Cited: 29th July 2010.] http://www.gapminder.org/world/#$majorMode=chart$is;shi=t;ly=2003;lb=f;il=t;fs=11;al=30;stl=t;st=t;nsl=t;se=t$wst;tts=C$ts;sp=5.59290322580644;ti=2008$zpv;v=0$inc_x;mmid=XCOORDS;iid=phAwcNAVuyj1jiMAkmq1iMg;by=ind$inc_y;mmid=YCOORDS;iid=pyj6tScZqmEcVezxiMl.


















