Mothers of Sarlahi

When Sajadi Khatun felt the familiar pain, she knew what to do: she, her husband, her mother and a neighbour quickly left their house in Laxmipur village and started the 20-minute walk to nearby Sundarpur Health Post. They did not get far. Ten minutes later, Sajadi delivered a baby boy on the roadside. 

After delivery, the tired new mother returned to her home on the outskirts of Sarlahi’s district headquarters Malangwa while the rest took the newborn — the family’s fifth child, and third boy — to the health post for a check-up. A nurse visited and found both mother and child health. 

“I wasn’t worried about giving birth on the roadside," says Sajadi, stoically, although she and her husband had wanted to deliver the new baby in the health post, like her previous three children. The first was delivered at home as there was no health post in the community at the time. 

Ahead of the last birth, Sajadi had gone to the health post for check-ups (known as ante-natal care, ANC, visits) eight times before her due date. Recently, Nepal increased the recommended number of ANC visits from four to eight, but in 2022 just 68.4% of women in Madhes Province did four or more ANCs. 

The local Female Community Health Volunteer (FCHV) had also visited her house many times. On the advice of those health workers, Sajadi was eating as healthy as possible to keep up her own weight and that of the baby. 

At the health post, Sajadi, who is not sure of her age but is probably about 30 according to the FCHV sitting nearby during our interview, also started taking calcium and iron supplements and got a tetanus/diphtheria vaccination.

Because the facility did not have an ultrasound machine, she and her husband, who do not own a vehicle, paid to go to a nearby private clinic and get the examination. It revealed no problems but staff there estimated her due date 20 days later than the actual delivery day. 

We do not know what would have happened if the ultrasound had been done at the health post, and produced a more accurate delivery date, but the roadside birth highlights again how lack of resources plays a role in maternal and child health in Nepal, despite the best intentions of health personnel and, of course, families. There was no ultrasound machine at the health post, and no ambulance to call when Sajadi’s labour started. 

“The problem is that we don’t have an ambulance in the municipality,” says Auxiliary Nurse Midwife Sunita Rai, who accompanies us to Sajadi’s house. “If we had an ambulance when a woman has a problem like a roadside delivery, we could send it right away and reduce the number of home deliveries.”

Sarlahi district, and Madhes Province overall, still have a high number of home deliveries. Statistics from the district health office show that 53.5% of births happened in health facilities in 2021-22. That leaves 46.5% occurring at home or en route to facilities. The Nepal Demographic Health Survey (NDHS) 2022 found that 66.6% of births in Madhes Province occur in a facility versus 79.3% for Nepal overall. 

“The health situation in Madhes Province is a little worrisome to us, despite all the facilities there,” said the secretary of the Ministry of Health, Roshan Pokhrel. “We’re thinking about giving different targets to different provinces, rather than having a central target,” he added. 

Nepal is aiming to reach the global Sustainable Development Goals (SDG) target of 70 maternal deaths per 100,000 births. The 2022 rate was 151, according to the NDHS. 

Read Also: This is how to upgrade Nepal's rural health, Sewa Bhattarai

In Sarlahi, health infrastructure is a key factor affecting maternal health. Medical Superintendent of Malangwa Hospital, Nawal Kishore Jha, told us that the facility has burst its seams. For example, when the Covid-19 pandemic displaced the emergency and in-patient departments, they moved to what was the waiting area, where they remain when we visit in April. 

Also, two years ago the hospital delivered one or two babies daily, but today it is closer to 20, including a growing number of Caesarean sections, yet the facility lacks a gynaecologist, meaning that non-specialists perform the 3-5 ‘C-sections’ done daily. 

Reached again on budget day, 16 June, Jha has good news: his hospital will be upgraded to a 100-bed facility. That could mean more buildings, more trained staff and equipment, including a CT scan machine. 

In case of a maternal emergency, accessing the district hospital — the best-resourced health facility in Sarlahi — should not be an issue as it is only a one-hour drive away from anywhere in the district, unless there is monsoon flooding, adds Jha. Yet as Sajadi’s example shows, lack of resources — like ambulances — can still be a barrier. 

While Jha and the nurses at health posts all say people’s awareness of maternal health and its potential complications could be higher overall, in the diverse communities near Malangwa, most women and their families are motivated to use health facilities, both to get as healthy as possible before giving birth and for the actual delivery. 

Besides awareness, living conditions are a major factor, says nurse Kanchen Rai at Laxmipur Khodra Health Post: “We can provide education, but the biggest problem is people’s lack of money. There has been some improvement but the poorest people still don’t have clean water and toilets.” 

“Pockets” that are away from urban areas and further marginalised by diverse factors are where home births still happen, and must be targeted for improvement, says Jha. 

First-time mother Rabena Khatun, 22, told us she felt “very happy” when she knew she was pregnant. Within three months she had visited the health post for her first ANC, following it up “3 or 4” more times before delivery, accompanied by her mother-in-law. 

Read Also: Midwives to the rescue, Laxmi Tamang

“The nurses told me I should eat more nutritious food so that I gain weight,” she tells us, crouching on the ground outside of her small thatch-roofed bamboo home, cradling her son Ehsan, now 37 days old, on her lap. 

When Rabena’s labour pains began, she went to the health post with her mother-in-law and two other relatives. After 10-12 hours the baby was born, without complications. Instructed by a nurse, the first-time mother started breastfeeding within 30 minutes. 

She tells us that no one in her family or community suggested during her pregnancy that she deliver at home, adding, “All the facilities are there (in the health post) so I felt confident.” 

Promise of a healthier district

The Medical Superintendent of Sarlahi District Hospital in Malangwa, Nawal Kishore Jha, sounded upbeat after hearing in the Madhes Province government budget on 16 June that the facility will be upgraded to a 100-bed hospital. 

“I’m very happy with the decision, it responds to all our demands,” Jha said on a call from Malangwa. The larger facility will receive more trained staff, more space, including to provide maternal healthcare services, and more equipment such as a machine for CT scans. 

The government also announced it would build two 50-bed hospitals elsewhere in the district, and that all other municipalities would have 15-bed facilities. 

The budget revealed that Sarlahi will become a 'completely safe motherhood district'. Among other things, that means all births will be in health facilities, accompanied by skilled health workers, and all pregnant women will have the required number of pre and post-natal checkups. 

“It is possible,” says Jha, “but it will take some time.”

Bumpy ride triggers birth

Anita Kumari Yadav had felt a pain for three days that she thought meant she was going into labour for her first baby. She walked to nearby Sisautiya Health Post, but was always told it hadn’t started. 

On the third day, nursing staff referred her to the district hospital because of the delay. When she arrived with her in-laws after a bumpy ambulance ride, she was told she would need a Caesarean section. 

“I was scared to have an operation,” says Anita, 20. She called her husband, a bus driver who was en route from Kathmandu. He told the family to wait until he arrived. But they didn’t have to. The baby was born half an hour later, one positive outcome of the bone-jarring ambulance ride, speculates Auxiliary Nurse Midwife Ringku Kumari Raut. 

Like the other women interviewed in the Malangwa area, Anita diligently did her ANC check-ups, once also visiting the district hospital to have a test confirmed. She took iron and calcium supplements (when in stock) and added fortified flour to her diet to gain weight. 

Nurse Raut says she is happy with how she and her colleagues managed Anita’s delivery, despite the health post’s limited resources: “Everything is fine now but if something had happened, the hospital had resources and facilities to deal with it.”

Maternal deaths deliver lessons

A day before the central government budget was released on 29 May, officials in the Family Welfare Division (FWD) of the Department of Health were resigned to the fact that the status quo was the most they could achieve in programming for the 2023-24 fiscal year. 

But Section Chief Gauri Pradhan had her fingers crossed that a verbal promise of more funding would allow the section to expand at least one program — for maternal and perinatal death surveillance and response (MPDSR). 

Started in Nepal at the Maternity Hospital in Thapathali in 1992, guidelines were created for the program in 2015 and revised in 2021. Today, MPDSR takes place in 42 districts, both in hospitals and where there are maternal and newborn deaths in communities. 

The promised funding, from an external partner, will permit the program to expand to more hospitals and communities. Pradhan displays the WhatsApp app on her mobile, which shows a group for reporting of mother and newborn deaths in hospitals and another for community deaths. 

Asked why this one program is likely to be the only maternal and newborn health initiative in the FWD to expand next year, Pradhan says: “It is the basic thing to take action to learn the cause of death. Without knowing the causes, how can we develop activities to make childbirth safer?” 

Expenses for this trip were paid by One Heart Worldwide.