Green Tara Nepal (GTN) has been implementing Safe Delivery Project for promotion of continuum of care from pregnancy to post-partum period Project, in Nepal in partnership with Karuna Germany, BMZ and Green Tara Trust.
Key FeaturesFunding/Partner Agency: Federal Ministry for Economic Cooperation and Development (BMZ), Karuna Deutschland e.V. and Green Tara Trust
Project Period: 2014-2017
Project District: Nawalparasi
Target area/population 2 birthing centers covering 4 VDCs
Total staff (at present) Project staff– 3
Health post staff (ANMs to local health facility- 4, cleaner/night guard-2)
Nepal suffers with double burden of health problems; communicable and non-communicable, which is further aggravated with poor nutrition. Maternal, neonatal and child health (MNCH) interventions are the crucial need of the country because of the multiple reasons.
In spite of significant success in improving maternal health, Nepal is one of the countries where maternal mortality is still unacceptably high. In rural parts of Nepal, median age for marriage is 17.7 years and one-fifth of the women become pregnant during adolescent period (DHS, 2011). Nearly 16% of the rural women do not seek any antenatal care and more than 50% do not complete four ANC as recommended by World Health Organization. More than one-third of pregnant women from rural area suffer from nutritional anaemia. Birth preparedness practices during pregnancy is poorer in rural areas than in urban, where 34% saved money, 3% arranged transport, 5% brought clean delivery kit, and nearly 40% had no preparation. DHS (2011) also showed that only 32% of the rural women compared to 72% of the urban seek services from skilled providers during their recent delivery period. Fifty-six percent of the women received no post-natal check-ups. Essential newborn care practices also needed to focus to improve neonatal health and to reduce neonatal and child mortality. Strengthening Family Planning information and services is another area to highlight since it is one of the major contributors in improving maternal health and overall development of the country. Moreover, HIV/AIDS is a growing concern for the country because of the population migration and increased unsafe sexual practices.
Poor status of women and adolescent girls is another big challenge for Nepal, especially in rural areas. High discriminations occur between male and female in terms of property holding and decision making. Only 9% of the women own land and 6% own house registered in their name. Only one fourth of the women can decide on their health care and one third can make decision to purchase household goods. Domestic violence is another big problem, where 22% of the women aged 15-49 years had experienced physical violence in their life time, of them nearly one-third had sought help from any sources.
Water and sanitation are other areas to consider for improving health of the people. Nearly 80% of the rural populations do not access to safe drinking water and about half of the population have no toilet facility and defecate in open place. Though hand washing is important to protect against communicable diseases, nearly half of the respondents from Terai did not wash their hands with soap and water properly.
The Ministry of Health and Population (MOHP) is responsible largely for health care delivery, although many NGOs are also providing health care. Nepal is committed to reduce maternal mortality ratio by three quarters between 1990 and 2015. The GON has given high priority to safe motherhood and neonatal health for improving maternal health in a holistic way. The national health policy (1991) and the Second Long Term Health Plan (1997-2017) have also given high priority to improve health status of the rural people. Therefore, the safe motherhood programme is highly emphasized in the current national plan to improve maternal health in Nepal. However, challenges are being faced due to lack of skilled health workers and poor health infrastructure, high staff absenteeism, especially in remote areas of Nepal.
Green Tara Nepal (GTN) has been working in poor rural communities since 2007. Programmes focus on maternal and child health and women’s rights and aims to assist communities to change health behaviour through health promotion strategies, whilst strengthening existing Government services. GTN combines both strategies as they believe this is more effective than strengthening service provision alone. GTN with their partners have published over 100 research papers and 10 books on reproductive/sexual health and research methodologies, and network effectively with local, national and international partners. GTN works in partnership with Green Tara Trust UK, an organisation that aims to work with the poorest, most marginalised and disadvantaged community groups in rural areas.
Since 2008, GTN has run a pilot intervention in Daxinkali and Chhaimale Village Development Communities (VDCs) of Kathmandu. Results in the first five years of the pilot showed vast improvements compared with the control area across the three main areas: maternal health, infant health and women’s empowerment. Amongst other things, this project resulted in 96% of pregnant women receiving antenatal care vs. 4% previously, and a reduction in the use of unskilled birth attendants from 38% to 14%.
As a result of this improvement seen in the hilly areas, GTN began its second project in Nawalparasi in 2012. Nawalparsi is a tropical region covering 2162 km2, with a population of 635,798 (CBS, 2011). It shares a southern border with India. It consists of three varying regions; mid mountain, the Siwalik Range and the plains or Tarai, which is where this project is situated. The district is made up of one municipality and 73 VDCs. The majority of the population lives in rural regions (93.08%). The target area for this project is two VDCs, Thulo Khairatawa and Bhujawata, with a population of approximately 10,000 people, living in small villages. GTN has an established presence in these VDCs and has been talking with the Health Facilities Management Committees (HFOMC) in both for the past 18 months. Both are keen to support the birthing center project and already have some infrastructure and budget for support. The District Health office and the two HFOMCs have been meeting monthly, and have now decided that one of the birthing centres should be located elsewhere. Both VDCs are centrally placed, making it easy for women from surrounding VDCs to get there, but they are also located close together. So the DHO will recommend another VDC for the second birthing centre.
Problems identified in the Project area
These VDCs are approximately 7 kilometres from the main highway that provides access to key services. Transport into the villages is non-existent; with most local people relying on bicycles. Families in these villages are very poor and saving money for birth in the health centre is almost impossible, including cost of the ambulance. The needs assessment also revealed problems with services at the sub health post level. These include low staffing levels, no electricity at times, lack of technical skills and interest in health staff. Research shows that the time taken to reach the health institution for delivery significantly influences delivery service utilisation (81%). Whilst all VDCs have a sub health post, they are not equipped for births. The nearest Primary Health Care Centre in the target VDCs is approximately 8 km away along a dirt road. The ambulance service is expensive and usually takes 4 hours or more to arrive. When women experience complications, they sometimes have to travel on a bull cart, which is dangerous and unsanitary and can take more than 2 hours to reach the health centre.
Other general risk factors for maternal and child health includes poor sanitation: not many households in these VDCs have a toilet (38%), and open defecation is still normal (61%); almost all households use a tube well or borehole for their drinking water, which are prone to arsenic poisoning. Maternal health care is also very poor in these villages, even by local standards. This is compounded by the fact that women’s status if very low. Only 13% of young women make their own decision about ANC and PNC check ups and place of delivery, and only 35% (2012 baseline) received all 4 recommended ANC check-ups vs 58.3% nationally. Many babies die due to preventable birth complications such as infections, preterm and birth asphyxia. This is because 70% of these women are still giving birth at home with no skilled birth attendant present. As a result an alarming number of mothers still die from preventable problems in these villages. In data collected Dec 2013, 1.7% of women had experienced a neonatal death and 1.2% had experienced a maternal death within the immediate family in the past 5 years.
Most maternal and newborn deaths occur at home and 70% of women in these villages still give birth at home with no Skilled Birth Attendant present. The nearest Health Care Centre for deliveries is approximately 8 km with no local transportation system in place, and research shows that the time taken to reach the health institution for delivery significantly influences delivery service utilisation (81%). When women experience complications, they usually travel on a bull cart, which is dangerous and unsanitary. In data collected in Dec 2013, 1.7% of women had experienced a neonatal death and 1.2 had experienced a maternal death within the immediate family in the past 5 years. This is exacerbated by the fact that women are disempowered in these communities: Only 13% of women make their own decision about the type of maternal care they receive; only 24% had first antenatal check up at 4 months as recommended by WHO; and 67% of women had no postnatal check up by a health worker.
A further problem in these communities is the isolation of young married women, particularly once they have a child. Most families do not allow the mother to leave the home unaccompanied, and once the baby is born, they are not allowed to leave the home until the baby is 5 years old. These women are very isolated and dependent upon husbands and mother-in-laws, who have outdated ideas about institutional childbirth.
ObjectivesOverall aim of this project is to promote continuum of care from pregnancy to post-partum period aim to reduce maternal and infant mortality in the target population. Specific objectives are:
• To increase decision making of women around health and reduced tolerance of violence.
• Increase access and coverage of pre-natal, institutional delivery and post-natal care, and FP services
• Mobilise health promotion groups to educate and empower women from some of the most marginalised castes who are less likely to access institutional delivery
• Create a supportive environment at health facility through technical and managerial support,
• Deliver quality of services through strengthening capacity of health workers, supply of basic equipments/instruments, technical support visits, etc.
Approach/strategies• Need based program planning and management addressing the gaps
• in partnership with DHO, health posts and local health facility and management committee
• Health promotion activities in the community level for demand creation of services
• Partnership with government counterparts and key stakeholders
Major Activities• Set up two birthing centres, including hiring two Auxiliary Nurse Midwives, a Community Health Worker and a Night-time attendant, buying equipment and refurbishing the space.
• Register both birthing centres with the Department of Health within one year of operation.
• Recruit women from neighbouring VDCs by outreaching to families and other NGOs
• Provide home visits to isolated women and families and support use of birthing facilities.
• Provide regular training and capacity building to Health Facilities Operations Management Committees, VDC staff, Health facilities staff and local volunteers such as Female Community Health Volunteers and traditional healers.
• Bring international medical volunteers to train local staff.
• Conduct mass events to promote health messages and the birthing centres.
• Conduct evaluation and disseminate findings nationally through journals and the media.
Key achievements• This was a new model of collaboration between governmental and non-governmental sector
• The people who were deprived of basic health services were benifited
• The programme is integrated for increasing demand for services and strengthening health services
Table 1: community based demand creation activities
SN Activities 2013 2014 2015 2016* Remarks Grp # Grp # Grp # Grp # Mother in-law 13 157 Women group 27 334 FCHVs 1 – HFOMC 1 –
* Total groups: from July – September 2016
Table 2: Coverage of MNCH services by HF
SN Activities 2014 2015 2016* Remarks Thulo Khairatawa Narsahi Thulo Khairatawa Narsahi Thulo Khairatawa Narsahi Total 1st ANC 131 Total 4th ANC 33 Total ANC Client 346 Iron intake in Pregnancy 229 Number of delivery case 53 19 Number of referral case 11 0