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Siddhartha Yadav on the challenges in reducing maternal mortality in Nepal

17 Sep, 09 | by julietwalker

Wednesday was an unusual day for the prime minister of Nepal. Right when he was about to leave for the capital from Nepalgunj in his helicopter, he received a call from one his acquaintances pleading to air-rescue a pregnant woman with placental haemorrhage from Rukum, a remote hilly district of Nepal.

And so a rescue mission started. The prime minister postponed a cabinet meeting and flew to Rukum and the lady with the haemorrhage was air-lifted to Kathmandu.

In Kathmandu, she was shifted to a government hospital in an unconscious state. Her haemoglobin at the time of admission was a mere 3.8 gm % (link to Nepalese newspaper). An emergency C-section was done. The baby was already dead.  The bleeding was stopped and she is now in intensive care unit, still unconscious.

I have mixed feelings about this story. For some, this is a success story in the fight to reduce maternal mortality with the prime minister himself leading from the front. Yes, a pregnant woman was saved from near death. And the prime minister did a commendable work, no doubt.

However, there are other aspects of this story that should not be neglected when planning the fight to reduce maternal mortality in Nepal. Situations like these happen more often in Nepal than not. This particular lady was lucky to receive a ride in the prime minister’s helicopter. What about the rest of them?

Others may not be as lucky. It is simply not possible for the prime minister to get involved in each and every individual case. It is a sad situation if the highest authority of the government has to personally get involved to save one pregnant woman. This just exposes the inadequacies of the existing state mechanisms in dealing with a situation like this.

Rukum is one of the remote hilly districts of Nepal. The highest health care centre here is the district hospital. There are doctors, nurses and midwives working in this hospital. However, the hospital does not have a proper blood bank, let alone facilities for C-section. The next bigger hospital is in Nepalgunj which is around a day’s journey away. Transfer of patients between hospitals is not the government’s responsibility either.

As a medical student we used to read of three delays contributing to maternal mortality: the delay in seeking care; the delay in reaching care and the delay in receiving care. Much of the focus of Nepal’s programs on reducing maternal mortality is on the first one: encouraging pregnant women to seek health care as early as possible.

Women receive a sum of money if they deliver at a health care facility. And these strategies have paid off to a great extent. Nepal’s maternal mortality rate has rapidly declined from 539 per 100, 000 live births in 1996 to 281 in 2006.

However, curtailing maternal mortality rates further will also need to address the other two delays. Transportation is a big problem within Nepal which creates the delay in reaching health care. Most of the remote villages are only accessible through walking and it sometimes takes days for them to reach the nearest health care facility. Porters are reluctant to carry pregnant women out of a cultural belief and it is very expensive too.

Local mother groups in some of the remote communities of Nepal generate enough funds to have ‘Doko’ ( A locally made basket to carry people and goods) and porters available at all times for transporting pregnant women free of cost. Sustainable mechanisms such as these can serve as an example to be extrapolated to other remote communities as well.

Transport from one health care facility to another referral centre is another big problem. It is solely the responsibility of the patient and the caretaker to do so. Ambulances can be costly and may not be easily available.  Alternatives such as planes and helicopters are still a very far- fetched idea for the poor and those without political connections.

I can only hope that this incident will make the prime minister and the health ministry think about the rest of the women who did not and will not get a ride on the prime minister’s helicopter. Hopefully, it will provide a stimulus for the government to create mechanisms at local level for transporting pregnant women needing urgent care that does not have to rely on calling the prime minister on a personal level.

Competing Interests: I am a research editor at Journal of Young Investigators (JYI), former Clegg Scholar at BMJ and have recently completed my medical school.

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  • Neena Khadka

    Dear Dr. Yadav,

    I think you have touched upon a very important issue in regards to the situation where the PM of Nepal rushed to the rescue and saved one woman’s life. Very commendable, as you state. I too am very happy for the woman saved and her family. However, just like you, I too would be very happy if this incident brought to attention the need for developing a system which would cater to all women in the country. A system, that probably needs to be designed to fit into the geographic settings they live in. A system, that not only provides the funds but also the facilities for women to go to. Your posting gave me hope, for I see we now have a generation of young doctors with an interest in saving lives in the country. May your tribe increase! neena

  • Deepak Paudel

    Dear Dr Yadav and Khadka,

    I agree with both of you that the PM’s interest and intention is
    commendable. But, I was surprized with the idea of helicopter ambulance
    after the event was happened. As a public health professional, we need
    to think about feasibility, cost-effectiveness and sustainability; so
    should try to extend services close to community (e.g. ensuring good
    service delivery within district iteself than lifting people in
    helicopters).

    But, I donot agree on the fact that reduction in MMR from 539 to 281
    between 1996 and 2006 due to the maternity incentives, as the incentive
    scheme was introduced in late 2005. The reduction is mostly due to
    reduced fertility and improved literacy and other socio-economic factors.

    Deepak

  • Siddhartha Yadav

    Dear Ms. Khadka and Mr. Poudel,

    Thank you for your interest on this blog. Indeed, we need to develop system that would cater to all women in the country in a feasible and cost effective manner.

    Mr. Poudel, I agree with your statement that reduced fertility and improved literacy had a great role in reducing maternal mortality. My reference was to strategies like “paying for delevering at a hospital” in general. Such strategies have had an important role in reducing maternal mortality in Nepal as well. In 2007 alone, 60,000 additional women were able to deliver in a health care facility as a result of this strategy (BMJ 2008;336:1459) (http://www.bmj.com/cgi/content/full/336/7659/1459)

    Obviously, it is very difficult to quantify how much reduction this strategy brought about in the maternal mortality. I agree with you that indirect social measures such as improved literacy had a huge impact, although, this again, is very difficult to quantify in figures.

    Thank you.

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