Late last year I returned to Chimling Village in Nepal’s Sindhupalchowk district to follow up on maternal health issues. I was impressed and disappointed at the same time.
I first visited the cluster of tiny cement houses at the top of a steep, rocky and rutted dirt road in March 2021. My goal was to trace an essential drug called misoprostol, which is used to stop bleeding after birth (also known as post-partum haemorrhage). There was a major shortage of the drug in 2020, so Nepal’s Ministry of Health had requested help from the international community.
I had already tracked the urgent requests for misoprostol from inside Nepal, the drug’s arrival in late 2020 and early 2021 via supply chains twisted by Covid-19, and its distribution to storage centres. But I wanted to see it being used on the ground by the women for whom it can mean life and death—those who give birth at home without skilled medical personnel.
Not only had the drug not been given to 9/10 pregnant women who did deliver at home, the female community health volunteer in the area didn’t even know about misoprostol until just one month before we arrived.
I was shocked by what we found (I travelled with the non-profit organization One Heart Worldwide) on that half-day visit: not only had the drug not been given to 9/10 pregnant women who did deliver at home (and to one woman only three days after she delivered!) the female community health volunteer (FCHV) in the area didn’t even know about misoprostol until just one month before we arrived.
The attitudes of the people we met were also surprising. Pregnant women, explained the FCHV, balked at delivering in health facilities for numerous reasons: the cost (although a government plan reimbursed most charges), and related to this, a belief that they might undergo unnecessary procedures, shyness, and a feeling that they would lose control over the procedure, including how long they would have to remain in bed and what foods they would eat.
Birthing centre finished but unstaffed
Local health staff didn’t appear worried that the brand new birthing centre wasn’t being used because some—but not all—nurses were away for training. And they didn’t appear to be in a hurry to visit women after they had delivered at home.
So I was very happy to see during our follow-up visit that the birthing centre was well-stocked and operating, and that more than a dozen women had given birth there since our first trip. We chatted with the one pregnant woman in the community, and she was planning to give birth at the centre rather than at home.
The two women I interviewed on the first trip were healthy as were their babies.
Then by chance a worker at the health post told us about a home birth that had occurred recently nearby. She couldn’t provide many details so we decided to visit ourselves.
We understood why it was a home birth
The house was nearby, a five-minute drive down the hill and a 15-minute walk along a rutted track. When we arrived and the new mother and her family told us their story we understand why she gave birth at home: the baby was two weeks early, the woman wasn’t sure if her labour pains were simply indigestion, and it was after midnight.
The frustrating part of her story was how the health system treated her. The FCHV assigned to the area (not the same woman mentioned earlier) did not visit her once during her pregnancy, although it’s part of her mandate. Also, no one from the health post made the trip to check on the health of mother and baby until we visited three days after the birth.
In the end, I think this experience strengthens the perception formed on my first visit: systems only work as well as the people tasked with carrying them out.
If you’d like to learn more, including the reaction of Dr. Lhamo Sherpa to this anecdote, listen to the episode of Nepal Now podcast devoted to my trip. It’s also titled More pills, Still no magic—Giving birth in the hills of Nepal, and is on most podcast platforms or the show’s website.