Sep 15, 2006

As a country with the notorious record of one of the highest maternal mortality rates, Nepalese women have suffered a lot in the last 12 years of conflict. The beginning of the peace process has injected certain hope among them. Following the devastation and disruption in health service, the overwhelming numbers of women have been denied the basic services. Large numbers of women are surviving amid taxing circumstances where they fall prey to various illnesses including the uteral prolapse, which is causing a high percentage of morbidity among them. After the ceasefire, the process of revitalization of health services has already begun. If basic health services are restored, lives of many women can be saved and their social status will change. Although the United Nations Population Fund (UNFPA) has already launched the mobile reproductive health camps to provide primary health services in rural areas, it is yet to be seen how effective they will be

By KESHAB POUDEL

Kamala Gurung, 22, a resident of Sikles Village of Kaski district about 250 kilometer west of capital, died due to complications during the delivery at mid-night a year ago. Although the medical assistant had advised Kamala’s family to take her to Pokhara hospital, the family members could not carry her at mid-night because of fears emanating from the insurgency.

Lukiyadevi Ram, 24 - a resident of Ramgunj Balgachiya village of Sunsari district - 500 kilometers south-east of capital Kathmandu - died of complications in pregnancy. Had she been taken to hospital on time, she could have been saved.

Kamala and Lukiyadevi are not the only ones who have died following simple complications in delivery. There are hundreds of thousands of women who have lost their lives in the last 13 years of insurgency due to unavailability of primary health services and disruption of transport networks due to insecurity.

Girls : Trauma of conflict and poor health

“Had health workers and medicine been available at midnight , she could have been saved,” said Chhote Ram, husband of Lukiyadevi. “Because of fear of land mines and cross firing, we could not take her to hospital. She died asking for help,” added Ram, a Madhesi dalit (untouchable).

The case of Ratna Kumari, 35, from Sarlahi who suffered from Uterine Prolapse or fallen womb as it is commonly known, is not too different. Her fallen womb, though it can be treated with just a minor surgery, has become a matter of discrimination in her family.

“Uterine prolapse best described as fallen womb is one of the most widespread reproductive health and social problems in Nepal . It has become a national tragedy. All over Nepal , hundreds of thousands of women are suffering from uterine prolapse. Its prevalence among women at reproductive age exceeds 10 percent and is as high as 24 percent among women between the ages of 45 and 49. Altogether more than 600,000 women are in urgent need of medical care,” said Junko Sazaki, country representative of UNFPA to Nepal . “What is even more tragic is that uterine prolapse is a preventable and treatable condition? But, unaware of this information and getting little support from the health workers around them who have equally little knowledge of the condition; the women cannot take preventive measures to avoid the condition.”

Thanks to the insurgency, a large number of country’s primary health posts and sub-health posts are either non-functional or destroyed making the large parts of Nepal devoid of basic health services.

According to the Ministry of Population and Health, over 60 percent of heath posts and sub-health posts in the rural parts of Nepal either were destroyed or without a good physical condition. Many remaining health posts are without trained health workers.

According to the Nepal Millennium Development Goals Progress Report 2005, over 80 percent of deliveries take place at home in Nepal . After the intensification of insurgency, the possibility of taking pregnant women to health posts came to an end and most of the births had to be assisted by family members and neighbors.

Women in Terai village : Cut off from basic health services

Prepared by the United Nations Development Program and National Planning Commission, the Report reveals that only one-fifth of deliveries are attended by health workers. Births attended by skilled birth attendants (doctors, nurses and auxillary nurse midwives) are as low as 11 percent. Another 10 percent of births were attended by traditional birth attendants, who may be trained or untrained; however, they do not qualify as skilled birth attendants.

Conducted by the Ministry of Population and Health, a study report shows that the cause of maternal deaths are severe bleeding, sepsis, toxemia, obstructed labor and the consequences of abortion. Most maternal deaths can be prevented if women have access to essential obstetric care service.

As most of the health assistants, auxillary nurses and mid-wives have deserted the health posts due to the threat of conflict, antenatal attendance is low. According to the Department of Health Services, only 14 percent women are attending the recommended four antenatal visits, and only about one seventh of adolescent mothers attending the antenatal clinic. Only 17 percent of women receive a post natal check within 48 hours.

In recent years, the conflict has impeded progress leaving many health facilities vacant or unsupervised. The abduction of health workers and insurgents looting medicine from health posts were common. The conflict left many impacts on the safe motherhood.

The health sector is yet to study its total cost of physical devastation in last one decade. According to the Asian Development Bank’s Measuring the Economic Costs of Conflict published in July 2005, economic performance has been affected through different channels. More than 12,000 lives have been lost and physical infrastructures worth at least US$ 250 million have been destroyed. The development expenditure declined at a rate of 4.2 percent during FY 2002-2004 compared with a growth of 10.4 percent during the period between 1991 and 2001.

Hopeful Signs

Although it will take years to rehabilitate the rural health systems and health networks, the ceasefire gives an opportunity to implement a new program to provide basic health services to women. This is a hopeful sign.

The past experiences have shown that reducing the maternal mortality depends on a functioning health system that provides skilled delivery services and essentials obstetric care.

As the country requires huge investment and time to make all health institutional functional, the government has already designed the short term programs including the mobile health service and temporary health camps in different parts of the country.

With the financial support from European Commission’s Humanitarian Aid department, the UNFPA has launched mobile reproductive health outreach services to conflict prone areas. The UNFPA launched the program in six districts of mid-western and far-western region.

“In a poor, mountainous country with Asia ’s second highest incidents of maternal mortality death, pregnancy and childbirth are made even more dangerous by the disruption of health services and transport,” said Sazaki.

As in any insurgency, women caught up in Nepal ’s low intensity war often bear the heaviest burdens but receive the least attention. The maternal mortality rate of 539 in 1000,000 live births is one of the highest in Asia .

“ Nepal has seen substantial improvement in RH status in terms of life expectancy at birth rising from 41 to 60 years during the last three decades, however, maternal mortality rate is one of the highest in the South Asia i.e. 539 per 100,000 live births. About 10 percent of women of the reproductive age are suffering from uterine prolapse which affects social and reproductive life of women,” said Dr. Mahendra Bahadur Bista, director general of Department of Health Services.

Other major causes are the insufficient number of trained reproductive health care service professionals, its facility at the periphery as well as unsatisfactory level of health care seeking behavior among the people occupied with poor socio-economic status. Only 13 percent of all presented deliveries are conducted by skilled health professionals with more than half not receiving any prenatal visits, and 92 percent of the births delivered at home where skilled birth attendants may or may not be available. Nepal also poses huge disease burden due to reproductive health disorder and related diseases and infections among reproductive age females in comparison to males. “Over 80 percent of Nepal ’s population lives in rural areas where basic health care service remains limited. According to the United Nation Population Fund, in addition to 10-years armed conflict has jeopardized the provision of basic health care services, exacerbating the lack of health workers, health facilities and medial supplies. As a result, the burden of the most common diseases including maternal illnesses which are estimated to grow by 100,000 new cases per year remains almost unattended,” said Junko Sazaki.

Along with other infrastructures, Nepal ’s health facilities, too, suffered a lot during the last 13 years of insurgency. In many districts, the country needs to completely renovate the health networks.

After the intensification of the insurgency, the government continued to reduce its annual investment in the health sector. In its annual budget of 2006-2007, Ministry of Finance increased its budget targeting the women’s health issues.

Although the safe motherhood and other women related health issues has been high on the national and international agenda, progress in overall situation is too slow as the conflict prevented the launching of effective programs.

At a time when large numbers of women are being denied the basic health service thanks to the conflict, which devastated basic health infrastructures in rural parts of Nepal , the United Nations Population Fund has come out with a mobile reproductive health outreach service to conflict-affected population. As overwhelming number of women have to sacrifice their lives without acquiring basic health facilities, this program has been announced as the first one after ceasefire opened an opportunity to go to village to take care of the women there.

“As the peace is relatively restored, the government is now working to carry out certain programs aiming to improve the health of women. The government will spend money to do surgical intervention to those women suffering from fallen womb,” said deputy prime minister and Health Minister Amik Sherchan.

Nepalese women are dying not because of major health complications but overwhelming because of simple complications, particularly related to reproductive health. As conflict eases and phase of reconstruction begins, the time has now come to provide some relief to women who have suffered a lot during the last one decade.