Factors That Persuaded Nurses to Establish a Maternity Care Centre in Nepal
by Laxmi Tamang
© 2009/2010 Midwifery Today, Inc. All rights reserved.
[Editor’s note: This article first appeared in Midwifery Today Issue 92, Winter 2009/2010.]
Nepal is a landlocked country nestled in the foothills of the Himalayas between India and China. It covers 147,181 square kilometres of the world with a population of 23.4 million, according to the 2001 census. It is a country of geographic and cultural wonders, including the Himalayan peaks, ancient temples and colourful marketplaces. Ecologically, Nepal is divided into three distinct regions: mountains, hills, and terai or plains. Nepal is predominantly rural, with only 14% of the population living in urban areas. Transportation is limited in the mountains and hills because of the steep terrain, but generally is more developed in the plains of the terai. Its per capita income is USD $270 and the vast majority of people are subsistence farmers. Its mountains, lack of infrastructure and landlocked status pose extreme barriers to the development and delivery of health care services.
Women’s Health Status and Services
From 1996–2006, Maoist rebels fought a civil war against the Nepal government, a democracy with a House of Representatives. As a result, the overall health situation of the country is poorer than it should be. For instance, availability of essential health care services is 78.8% and life expectancy is 60 years. As in other developing countries, diseases of pregnant women and children, infections and malnutrition account for two-thirds of Nepal’s illnesses.
Women in Nepal face discrimination and marginalisation in the family, society and state. This is because of the low status of women in the society. As a result, in a country where the health system is already poor, the level of women’s health and education is particularly low. To compound the problem, many districts of Nepal are remote, making access to health services and information very limited.
Reproductive and maternal health is of particular concern among Nepali women. In Nepal, the key role of a woman is to bear children, particularly sons. In fact, early and excessive childbearing weakens women, many of whom die or are chronically disabled from complications of pregnancy. It is not uncommon for Nepali women to experience a prolapsed uterus following birth. This is often due to recommencing, too soon, the expected workload, which is demanding and strenuous. Often, the prolapse remains untreated and women continue their remaining reproductive life miserable due to pain and suffering.
Pregnancy is taken as a natural process and God’s gift, for which any medical care is regarded as unnecessary. As a result, a majority of Nepalese women have been suffering from the aforementioned problems and complications related to childbirth. Because their overall health is poor, they have very little opportunity for exercising their reproductive and human rights. The majority of Nepalese women have no pregnancy-related contact with modern health services and maternity services in Nepal are very poor, underused and of poor quality.
According to the Nepal Demographic Health Survey (NDHS) 2006, 44% of women receive antenatal care from skilled birth attendants (SBAs), that is, a doctor or nurse-midwife; only 29% of pregnant women make antenatal care visits during their pregnancy; and less than 19% of births take place with the assistance of SBAs in a health facility, whereas 81% take place at home. Most of these homebirths are assisted by family members, neighbors, or traditional birth attendants who may be trained or untrained; or the woman may be on her own. A large proportion of maternal and neonatal deaths occur during the 24 hours following delivery. In addition, the first two days following delivery are critical for monitoring complications arising from the delivery. However, only one in five (20%) women receive postnatal care within four hours of delivery; slightly more than one in four (27%) receive care within the first 24 hours; and four percent are seen within one or two days following delivery. Each day in Nepal, 12 mothers and 75 babies die in childbirth.
The fact that 67% of maternal deaths take place at home and a further 11% on the way to hospital, coupled with the fact that 47% of deaths are due to postpartum haemorrhage, strengthens the case for skilled attendants both in the community and in accessible institutions (Pathak et al. 1998). Most of the mothers die of severe bleeding, a complication that can be treated even in basic health centres. The maternal mortality ratio (MMR), an indicator of the overall health of a population, stands at 281 deaths per 100,000 births in Nepal (NDHS, 2006). This is among the highest in the world. In comparison, the MMR is 90 in Sri Lanka and just eight per 100,000 in the US, according to the World Health Organization. Similarly, the perinatal mortality rate in Nepal is also one of the highest in the world (75 per 1000 live births).
In Nepal, one woman dies every four hours from complications related to pregnancy and childbirth. The presence of a midwife could save many of them. Having a skilled professional at birth protects the life of the mother and the child by recognizing problems early, when the situation can still be controlled, and by intervening quickly. It is universally recognized that unless and until a country can produce high quality and adequate human resources for health at the levels needed by that country, it will not be able to make qualitative improvement in the health sector. The production of high quality human resources in the health sector at various levels must be based on a country’s needs and the priority of the service. For instance, improvements in the maternal and neonatal mortality and morbidity rates have occurred in developing and developed countries, such as Sri Lanka, Cuba, Malaysia, Thailand, England, China and Sweden, through the implementation of strong midwifery and nursing education and effective management of maternal and neonatal health problems (Maclean 2003; FCI 1997; Cardoso 1986; Royston and Armstrong 1989; Högberg, Wall and Brostrom 1986).
In the 1990s, Nepal invested in two types of health workers to provide maternal/child health services and obstetric first aid at the village level: Maternal and Child Health Workers (MCHW) and Auxiliary Nurse Midwives (ANM). Neither category of worker has successfully functioned as a skilled birth attendant due to a number of factors. These include inadequate length of the midwifery component of the training; lack of competency-based training; lack of adequate clinical training and experience; professional and social isolation at post; and lack of support from the health system to enable MCHWs and ANMs to provide quality emergency obstetric and neonatal care, especially during life-threatening complications.
Since less than 19% of births take place with the assistance of an SBA, Nepal has a challenge in achieving the Millennium Development Goals (MDG) to reduce child mortality and improve maternal health (MDG 4 and 5 respectively) by addressing factors related to various morbidities, death and disability caused by complications of pregnancy and childbirth. The targets for SBAs set for the country are: 40% of all births to be assisted by an SBA by 2005, 50% by 2010, and 60% by 2015. In order to achieve this target by 2015, a total of 4907 SBAs must be in post by 2012 (from 2395 at present) (GON 2007). This is an enormous challenge because currently, as per the internationally accepted definition, only a limited number of health workers in Nepal qualify as SBAs. Furthermore, unequal access to SBAs, depending on the area in which one lives and one’s economic status, is a barrier to achieving these MDG indicators. Fifty-one percent of deliveries in urban areas are attended by an SBA, compared to 14% of births in rural areas (NDHS 2006). Against such a backdrop is a need to produce skilled birth attendants who can proficiently deal with these national maternal and child health issues.
Starting a Maternity Service
In April 2007, after I returned from completing my Master of Public Health degree in Australia, I started work as a lecturer at a private health science college that offered a bachelor of public health and a nursing program. I noticed that health education was privatized and the fees charged by such colleges were extremely high. These colleges were mainly established by business people to generate money; therefore, quality of education was not the priority. Students would graduate having had academic experience with limited faculty members and poor practical exposure in clinical and field placement. This worried me, as I thought about how these students would be able to compete with other candidates to find jobs after graduation. On the other hand, faculty members were paid low salaries and expected to work longer hours with no additional benefits during the practical placement of students. As a result, I was not satisfied with what I was doing and felt exploited because I thought I was playing a major role in ruining the future of the students.
Aadharhut Prasuti Sewa Kendra (APS Kendra) was established through the partnership and personal contribution of 11 nurse-midwives in July 2007. It is community-based and provides maternal and child health services around the clock. It is the first and only nurse-midwives-led freestanding birthing centre in Nepal that provides seven-days-a-week, specialized, quality, cost-effective, integrated reproductive health services by qualified and experienced nurse-midwives and nurses. Founding members are compassionate, devoted and committed; the nurses give mothers confidence and the belief that they are receiving the best maternal and child health care and services; and the services are culturally sensitive and affordable to all families. APS Kendra provides both outpatient and inpatient services that include:
- antenatal check-ups, delivery in a home-like environment accompanied by husband or relative, and postnatal care (including a home visit on the second day following the birth);
- family planning services, including sexually transmitted infections case management and treatment;
- integrated management of childhood illness, immunization, and routine growth monitoring for children under five years old;
- comprehensive abortion care (only up to 12 weeks gestation, as per government policy);
- screening for cervical cancer (PAP smear test);
- consultant Obstetrician and Pediatrician visits;
- referral services;
- HIV/AIDS voluntary counseling and testing (VCT);
- home visits;
- education and counseling for other reproductive health-related problems.
In addition to the above, the centre conducts bi-annual free health camps for women in conjunction with women’s festivals, e.g., International Women’s Day and a national women’s festival called TEEJ. Other services include a laboratory facility for basic investigations, ultrasound and pharmacy. APS Kendra also provides a platform for nursing students by placing them in on-the-job and field-placement training, as well as offering the opportunity to do research.
APS Kendra targets all women, children and families, especially poor and underserved families with middle-low and low-level income from both inside and outside the valley, who are beyond access to the costly maternity services in the private modern hospitals, maternity homes and clinics, in order to break the economic barrier to access and use of maternal and child health services.
Besides the aforementioned facts and figures, other factors led to formation of the group. Firstly, we realized that the time was right to promote the concept of a natural birthing centre run by nurses. The Government of Nepal had developed a policy to produce skilled birth attendants to mobilize in improving maternal and neonatal health status in the country to meet the Millennium Development Goals. And despite being educated professional women, nurses had never done any sort of initiative independently or on their own. Secondly, we realized that the private sector nursing colleges were producing nurses in large numbers, but the quality of their education was lacking due to limited clinical placement in hospitals, especially for midwifery. Those nurses who had graduated from these colleges usually had to work as volunteers in private hospitals for a year to obtain the experience needed to get a job. We believed that these hospitals were exploiting our juniors because they did not even pay a minimal allowance, even though the students’ parents had invested a lot of money in their study in the belief that they would get a good job after their graduation. (Even to get such a volunteer job, they have to go to four or five private hospitals, hoping that someone there knows them.) Thirdly, a city like Kathmandu has too many private hospitals—none of which serve poor people—and three semi-government-run hospitals to provide maternity services: Thapathali Maternity Hospital, Maharajgunj Teaching Hospital and Patan Hospital. Among these there is only one Maternity Hospital, which is the only tertiary level Maternity Hospital in Nepal and it is always crowded. According to our knowledge, experience and evidence, clients are compelled to go into this hospital because the other two are more costly. Also, clients are not satisfied because of the low quality of the services, the nurses’ attitudes and behavior, and the hospital environment.
Our organization’s mission is to provide quality, cost-effective, basic maternal and child health services—including integrated reproductive health services—especially to poor urban families in the Kathmandu valley. To do this, the group’s objective is to provide these services in a friendly manner by qualified and experienced nurses and consultants. Our aim is to be a model institution in promoting independent natural birthing centres in the country, offering a site to train and support skilled, compassionate SBAs, including nursing students. We also want to provide a platform for newly graduated nurses to work under the direct supervision of senior nurse-midwives by providing minimal allowances for public transportation and refreshment.
The top priorities for our group for the next two years will be strengthening, expanding and developing the sustainability of quality cost-effective youth-, woman- and couple-, and child-friendly reproductive health and child health care delivery services to the targeted group. Without these it would be difficult to provide effective and efficient delivery of services. Furthermore, we are also planning to run midwifery courses in accordance with the National Skilled Birth Attendants Policy 2006 by establishing a midwifery school, which would be a pioneering event since no such school or course has been developed to date in Nepal. Nevertheless the demand for producing skilled birth attendants to conduct safe deliveries is high in order to meet the Millennium Development Goals.
Since our group is working with poor, urban families to improve the health conditions of mother and baby during the prenatal, childbirth and postnatal period and among children under five years old, our major challenges include encouraging these women and their family members to deliver their babies in the health facility under the direct supervision of skilled health workers. According to the Nepal Demographic Health Survey 2006, although 84.6% of Nepalese women receive antenatal care during pregnancy in urban areas, the majority (52.5%) of them give birth at home. Likewise, only 50.6% of them are assisted by skilled birth attendants (doctors and nurses) during the delivery and a large percentage (45.7%) of women do not go for postnatal check-ups following childbirth. When we analyzed these figures we found that most of the women who do not seek these services are urban poor, wives of migrant labourers from outside the Kathmandu valley. Therefore, we are challenged to improve these situations.
The service charges of APS Kendra are kept minimal, considering the financial status of the targeted groups. Fees have included, for instance, US $0.33 for new registration and US $22.08 for normal delivery—including medicines, supplies and bed charge, and a free home visit on the second day after discharge. In the case of the government-run Maternity Hospital, Thapathali, fees for a normal delivery would be around US $24, and in the semi-government run Patan Hospital they would be US $57. Neither hospital has a home-visit service for postnatal mothers. We have fixed our service charges based on a household-level survey of 300 families, conducted to identify their perspectives toward establishing nurse-midwife-led maternity services and on the cost for those services. We incorporated the findings of the survey to match the needs and demands for services and costs according to community preference, which I believe is the first and only private health institution that was established incorporating such survey findings.
The nurse-midwives in our team are from different health organizations, both clinical and academic. Three nurse-midwives are from Patan Hospital and have had 17–31 years of clinical experience in maternity; two nurse-midwives are from Maternity Hospital; and five registered nurses have a Masters of Public Health or a Masters in Nursing degree in Women’s Health and Midwifery and are from the academic sector. The founding members volunteer time to perform shift duties and promotional activities, and to oversee management and supervise day-to-day service delivery. APS Kendra is guided by the principles of quality cost-effective service, equitable access, social justice, community participation, private-public partnership, human rights and sustainable development. Through its trained nursing staff, it provides cost-effective, compassionate and quality maternal and child health care services. The APS Kendra team acknowledges that since health care services have a direct impact on individual well-being, it should not discriminate based on the individual and family’s economic status, and believes that quality health services need not always be an expensive commodity limited only to those who are rich enough to afford it.
It’s been two-and-a-half years since APS Kendra’s establishment in July of 2007, and at present we are facing a challenge in terms of sustainability because of the Nepal government’s recently introduced policy to provide free maternity services to all women who give birth in a public health institution, in an effort to meet Millennium Development Goal 5. After signing the memorandum of understanding with the Ministry of Health in September 2009, APS Kendra is now also providing free maternity care service through its birthing centre, for normal births. Besides this, to run an organization with support only from women in a country like Nepal is itself a challenge. However, APS team members are dedicated and committed to providing quality cost-effective service to urban poor families despite facing these challenges. Fortunately, we have good coordination and cooperation with the District Public Health Office in Kathmandu, from where we get family planning devices and vaccines that APS Kendra provides free of cost. We also report to them monthly.
We anticipate that one day we will get support and cooperation from national and international senior colleagues, individual experts, groups, institutions and organizations, to work collaboratively so that evidence-based maternity and midwifery practices will improve the conditions of the women and children of Nepal. We expect to do so by delivering cost-effective, quality, evidence-based services, thereby achieving Millennium Development Goals 4 and 5, and improving maternal and child health.
Laxmi Tamang has a Bachelor of Nursing from Nepal and a Master of Public Health from the University of New South Wales in Australia. She has extensive experience working in different settings, with diverse communities, in hospitals, national and international developmental agencies and educational institutions since 1995. Laxmi is committed to promoting independent midwifery practice in Nepal, raising the standards of nursing and midwifery education, and working to ensure safe motherhood, reproductive health and women’s empowerment. Under her leadership, the first and only independent nurse-midwives-led birthing centre was established in Nepal in July of 2007.
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