Transforming the way women are medically treated in rural Nepal
Women suffer disproportionately from access to quality health services in rural Nepal. Although the frequency of maternal deaths in Nepal has significantly reduced, pregnancy-related complications such as fistula and uterine prolapse remain high, especially in rural areas. VSO volunteer public health nurse Cath Nixon works alongside local health workers in a district hospital and across villages in midwest Nepal to improve and raise awareness of the care vulnerable women receive before and after pregnancy.
Making the journey
At eight months pregnant, Radha Kaundel travelled the long journey from her village to attend her fourth and final antenatal check-up in Dailekh District Hospital, the largest health facility for miles; “previously, the young nurses were not respectful to patients...but the way Cath is teaching the nurses here is very good that’s why I chose to come here,” she explains.
In spite of financial incentives for women to attend all four antenatal checkups more than two fifths of mothers in Nepal do not complete all four recommended antenatal visits. In Dailekh, where Nurse Cath Nixon has been placed as a VSO volunteer for two years, just over half of women come for all four appointments.
Neglecting to engage with antenatal and postnatal healthcare puts thousands of Nepali women and their newborn babies at risk. “Even though maternal mortality rates are dropping in Nepal, infant mortality rates are still quite high. So it's really important to get the woman to engage with the local health centre,” says Cath.
During the first part of her placement, Cath spent time observing nurses and standard practice at Dailekh hospital, trying to understand why women weren’t returning for their checkups, “It was very difficult initially, lots of women would be in the clinic at the same time and there wouldn't really be any privacy. I noticed patients weren’t really respected, sometimes nurses were quite abrupt and sharp – it was an environment you wouldn’t really want to return to as a patient.”
Research in Nepal also highlights that women avoid going to hospital because they're scared their privacy won't be maintained; that people will examine them and that it won't be a pleasant experience.
After forming a good relationship with nurses at Dailekh district hospital, Cath slowly started introducing small changes to shift the emphasis from routine tasks to meaningful engagement with pregnant patients who’d travelled from distant villages to attend their antenatal checkups, “When a patient comes in it's not just about taking a patient’s blood pressure, checking their weight, giving them medicine and sending them on their way, but it's actually about finding out about that individual's own story, what problems she has, how she's feeling that day, any anxiety she's having, trying to see what she knows about taking care of herself and building on that instead of just giving her a reeled-off speech.”
Bharat Kumari is one of the Nepali nurses who’s taken on board some of the skills Cath has shared, “What we learnt from Cath is to give sufficient time needed to each patient and fulfil her needs,’ she says.
Informed patients lead to healthier women and babies
More important than having happy, smiling patients is the real engagement that results from educating rural women who rarely access health services through effective antenatal care. A high proportion of pregnant women suffer from malnutrition in Nepal and struggle to breastfeed; both are problems that can be alleviated by educating women during hospital visits.
Cath has introduced ways to make breastfeeding and nutritional training meaningful and enjoyable for both nurses and patients by using simple, low cost health education tools, “by using simple visual aids like a nutritional wheel that shows the different food groups a woman should have in her diet or a straw in a cup to demonstrate how to breastfeed effectively; you’re making the patients the expert as well as the nurses,” explains Cath.
Since Cath has introduced public health education training and inculcated behaviour change at the clinic, she has seen a real change in the way patients are reacting, “I've noticed that women are starting to talk back, they actually ask questions because they are interested and given the opportunity.”
Tackling the root causes
Cath believes a real transformation in women’s health and a reduction in maternal morbidity can only happen if changes in the hospital are tackled in tandem with the various complex social and cultural barriers that prevent women from receiving the care they need. “Lots of women don't even know about the health centre, or their families don't let them go to hospital...many need to get permission from their mother-in-law or husband before they actually can access health services, or don’t understand the importance of coming,” she says.
A core part of Cath’s work with VSO involves working with partner organisation WEAF (women’s empowerment action forum) across eight villages to reduce high rates of uterine prolapse and increase women's reproductive health rights through awareness raising, improving treatment, and advocating for women.
By the end of her two years in rural Nepal, VSO volunteer Cath will have worked to improve the skills and practice of over 20 nurses at Dailekh District hospital, created a culture of public health education in antenatal and postnatal clinics, and spread awareness of critical women’s health issues to countless women in villages across the Himalayan Midwest region on Nepal.