Nepal: Maternal & Neonatal Care by Doctors of the World

ARCH 2013 8M

ARS 2013 8M

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Conception : Aurore Voet / Médecins du Monde

8 march 2013

TO CHOOSE THEIR OWN LIVES

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International Women’s Day Press kit 8 march 2013

éditorial In 1994 the Cairo Conference marked a significant shift when it introduced and defined the concept of sexual and reproductive health. It was no longer simply about maternal health but “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and to its functions and processes. Reproductive health therefore implies that people are able to have a satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when and how often to do so.” Almost 20 years later, there is no denying that, while some progress has been made, it has been limited and women are often still denied their full rights. At least two countries in Latin America have revised their criminal code to ban abortions, even in cases of rape, incest or where the woman’s life is in danger (El Salvador in 1998, Nicaragua in 2006). Doctors of the World (Médecins du Monde – MdM) has chosen to make sexual and reproductive health one of its priorities, focusing on the public health impact and a desire to take action to promote respect for the sexual and reproductive rights of everyone. In 2010 it was estimated that 287,000 women died in pregnancy and childbirth. Of these deaths, 99% occur in developing countries, with 85% of these occurring in sub-Saharan Africa and South Asia. In countries such as Chad and Somalia the maternal mortality rate is higher than 1,000 per 100,000 live births. The maternal mortality rate is a very good indicator not only of women’s health but also of how well a healthcare system is functioning. Nevertheless, it does not reflect the full complexity or the political dimension of sexual and reproductive health. In 2012 it was estimated that over 200 million women worldwide have unmet family planning needs and over 20 million women will resort to a high-risk abortion. At least 13% of maternal deaths can be attributed to

high-risk abortions and millions of women suffer from the temporary or permanent consequences of such abortions. Violence against women remains extremely widespread – around one in five women worldwide will be a victim of rape or attempted rape during her lifetime1. Our programmes are implemented by means of a dual approach based on public health and human rights. Thus we focus on the provision of comprehensive, accessible, high-quality healthcare, which strengthens the continuum of care, and advocacy of sexual and reproductive health rights. Recent progress is based on respect for rights and greater participation by women in decisionmaking at all levels. However, it also relies on the political will of states to guarantee fair access to healthcare for all, as in Nepal, for example. The work of Doctors of the World aims to improve the availability of sexual and reproductive health services and to guarantee access to these services. Socio-economic determinants and gender inequality hinder women in their everyday access to healthcare (for example, the cost of services, as well as women’s lack of decision-making power, freedom of movement and opportunity to manage their finances). Through our programmes on the ground we are developing our advocacy work, especially in relation to the prevention and management of unwanted pregnancies, the removal of financial barriers to healthcare and capacity-building among women.

Catherine Giboin, Doctors of the World Sexual and Reproductive Health Group Manager 1. María José Alcalá, State of world population 2005. The promise of equality: gender equity, reproductive health and the Millennium Development Goals, UNFPA, 2005, p. 65.

Ivory Coast © Sébstien Duijndam

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TCHAD © Raphaël Blasselle

LAOS © Lâm Duc Hiên

Press kit 8 march 2013

Understanding Nepal’s health challenges

As a nurse/midwife, I try to raise awareness among women of their own health. Many mothers-in-law, who themselves had to go back to work in the fields within days of giving birth, don’t believe things should be any different for their daughtersin-law. This is why I have to make pregnant women aware of the need to rest before and after delivery and the importance of adjusting their diet during this period. Attitudes are changing, but there’s still a lot to be done. Many women don’t know what they are entitled to or where to find the care they need. They don’t know what they need as women”. Srijana Lama, senior nurse in Sunkhani

; While the average maternal mortality rate in developed countries is 16 per 100,000 births2, in Nepal the rate is 170 maternal deaths per 100,000 births3. Ranked 157 out of 187 in the Human Development Index4, the country is still seeing the consequences of 10 years of violent conflict between forces loyal to the King and Maoist insurgents, despite the signing of a peace accord in 2006. The ongoing political disputes and the anticipation of a new Constitution since 2008 prevent the interim government from tackling the country’s economic and social problems. From the healthcare perspective, the Nepalese government set out a very advanced healthcare system in its Constitution. However, in reality the huge social and geographical disparities hinder an effective implementation of the system and the quality of care and access to it remain inadequate. The economic burden imposed on families by the use of maternal health services is still very high and the availability of these services at healthcare facilities is frequently poor. Doctors of the World has been working in Nepal for over fifteen years, through projects ranging from community development to combating HIV and tuberculosis. Since 2007 Doctors of the World has been active in isolated communities in Sindhupalchok district, particularly among women of childbearing age. The aim of our programme is to increase the use of public sexual and reproductive health services and to reduce factors contributing to maternal and neonatal mortality. The Doctors of the World project sets out to ensure the availability of high-quality health services at community level (renovating and providing equipment for health centres, training health workers and facilitating referrals to other healthcare facilities). It also aims to build capacity among women in relation to access to health services. The element which makes this project original and sustainable is the involvement of women in micro-finance activities and education sessions on preventing and managing pregnancy, childbirth and the postnatal period.

2. www.who.int/mediacentre/factsheets/fs348/en/index.html 3. www.who.int/gho/countries/npl.pdf Nevertheless, according to the 2012 Nepal Demographic Health survey, the average maternal mortality rate is 281 deaths maternal deaths per 100,000 births. 4. http://hdr.undp.org/en/statistics/hdi/. 4

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Press kit 8 march 2013

ACCESS TO HEALTHCARE FOR ALL IN THEORY

On paper – a healthcare system making real progress The last 20 years have been marked by a realisation on the part of the government of Nepal’s deficiencies in terms of health. A network of healthcare facilities has been established across the country through primary healthcare centres and district hospitals. In addition, support has been provided for the training of medical professionals. Since 2008, the interim Constitution has guaranteed basic medical care as a fundamental human right for the citizens of Nepal. Essential healthcare and some vital medications are now available free of charge at healthcare facilities and at the district hospitals emergency care and medication are also free of charge for vulnerable people and marginalised groups.

Advances in sexual and reproductive health The recognition in the Constitution of reproductive rights as fundamental rights has enabled significant progress to be made in the field of sexual and reproductive health. Between 1990 and 2010 the maternal mortality rate fell by 78%5. The last decade has seen the introduction of a number of government measures: for example, pregnancy education campaigns, increasing the reach of antenatal care, raising the legal age for marriage, the development of family planning programmes and improvements to road conditions to facilitate referrals to other healthcare facilities. In 2009 care during childbirth was made free of charge in state hospitals, enabling safe childbirth services to be extended to all women in Nepal. The legalisation of abortion in 2002, following an influential civil society campaign, and the establishment of services for women seeking abortion in 2004, were also major factors in reducing maternal mortality.

The cost of these services and difficulties in accessing them are a major obstacle for many women.

� Millennium Development Goals In practice – a healthcare system which is difficult to access for certain groups Although the Nepalese healthcare system in theory guarantees the right to health for all, in practice this guarantee remains fragile. Simply making health services available is by no means the same as guaranteeing that they will be used: today only 48% of women use contraception, even though family planning services have existed since 1968. People living in rural communities, that is 87% of the population of Nepal, have much poorer access to health services than those in urban communities. This is particularly true of pregnant women: the number of births attended by skilled health workers is 52% in urban areas, whereas this figure drops to 19% in rural areas6. This issue is further highlighted by the lack of health workers in rural health centres. They are few in number and prefer to go and work in urban areas or in private healthcare facilities. The cost of these services and difficulties in accessing them are a major obstacle for many women, especially with the additional cost of medication or transport to a health centre which may be several days’ walk away. All these pressures are still more problematic for women who risk developing obstetric complications requiring emergency medical attention (on average 15% of pregnancies).

In 2000 the UN adopted eight goals to be achieved by 2015, of which Goal 5 is Improving maternal health. It aims to reduce by three quarters, between 1990 and 2015, the maternal mortality ratio and to achieve, by 2015, universal access to reproductive healthcare. At the global level, the UN notes that the current figure

for maternal deaths (287,000) represents a reduction of 47% compared with 1990. The Goal also stresses the need to increase the proportion of births attended by skilled health workers6. Nepal has achieved its goals, with a maternal mortality rate under 213 per 100,000 live births7.

The nurses and midwives are usually recruited at governmental level to work in state healthcare facilities. However, there is a worrying problem with absenteeism. The absence of skilled health workers makes a negative impression on women who have walked for several hours to consult them. After an unsatisfactory experience like this, they won’t come back, thus exposing themselves to the risk of complications which may have a significant impact on their health. Doctors of the World and its partner Community Development and Environment Conservation Forum (CDECF) have trained and recruited nurses/midwives who work in various healthcare facilities supported by MdM. They fill the gaps between what is set out on paper and what exists in reality on the ground”. Kamala Adhikari, Technical supervisor on Reproductive health

5.www.unfpa.org/webdav/site/global/shared/documents/publications/2012/Trends_in_maternal_mortality_A4-1.pdf 6

6. www.who.int/gho/countries/npl.pdf

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7. www.undp.org/content/undp/en/home/mdgoverview/mdg_goals/mdg5/ 8. www.who.int/gho/publications/world_health_statistics/EN_WHS2012_Full. Press kit 8 march 2013

WORKING TO HELP REDUCE MATERNAL AND NEONATAL MORTALITY IN SINDHUPALCHOK

In Sindhupalchok District the geographical challenges are significant and contribute to the lack of access to information among isolated populations. Through the MdM programme we educate women about their rights and where to find health centres. Health is a fundamental right, it is essential if you are to have control over your own body. A woman should never have to wait for someone to give her permission and the money she needs to access health services. An ophthalmologist told me the story of a widow who lived with her son. She suffered a serious eye injury but waited for three days until her son came back from work so she could ask his permission to go and see a doctor. If she had gone three days earlier, the treatment would have been much less severe”.

� Doctors of the World and Sindhupalchok Sindhupalchok is one of the 75 districts of Nepal. It is divided into 79 village development committees (VDCs), including Chautara, the district administrative headquarters. Having identified significant needs in terms of healthcare and an absence of medical NGOs, in 2011 Doctors of the World extended its micro-finance and health education programme to ten new VDCs. In relation to sexual and reproductive health, the statistics for the district are alarming: 30% of births are attended by skilled health workers, 35% of women use contraception and 20% of VDCs have basic transport for referrals to other healthcare facilities. Working with the health authorities, Doctors of the World decided to run a programme to improve availability of healthcare services, in particular sexual and reproductive health services.

Altogether, over 45 medical and paramedical employees have been trained in obstetric and neonatal care.

Sumina Shrestha, coordinator of the CDECF programme

Improving access to and availability of sexual and reproductive health services9 In response to the need to improve healthcare provision, MdM is strengthening and developing a sustainable health network. It is ensuring an ongoing presence in the form of nurses who provide technical support at the various health centres supported by the organisation, and is working together with national and local bodies, as well as partner NGOs. Doctors of the World has funded the renovation of nine healthcare facilities since 2007. The programme intends to set up delivery rooms at each health post and to develop basic emergency obstetric care services at some healthcare facilities in partnership with the district health services. MdM is currently working in 12 healthcare facilities. The programme covers training for government health workers at all the healthcare facilities supported by the MdM teams and the recruitment of ten nurses/auxiliary midwives. Altogether, over 45 medical and paramedical employees have been trained in obstetric and neonatal care. The programme aims to make skilled health workers available for the provision of round-the-clock emergency care. At the same time, Doctors of the World is providing the health centres with sexual and reproductive health equipment, including delivery beds, sterilisers and baby weighing scales. Stretchers have been provided to enable easier transportation to the health facility for women about to give birth, since distances can be considerable and roads difficult to negotiate.

I see many women suffering from prolapse, diarrhoea, vomiting… In order to get to the health centre people have to travel for two hours by bus or six hours on foot. Between 20 ands 30 people come to be seen at the health centre every day. There isn’t enough medication and the delivery room should be larger, better lit and better equipped. Some women know the symptoms of pregnancy complications but others are uneducated and it’s difficult to convince them that they might have health problems or to advise them to come and give birth at the centre rather than at home”. Ang Lahnu Sherpa, nurse/midwife in Thokarpa

9. Sexual and reproductive health: http://www.medecinsdumonde.org/NosCombats/Priorites-d-action/Promotion-de-la-sante-sexuelle-et-reproductive-SSR 8

Doctors of the World

Press kit 8 march 2013

SUPPORTING ACCESS TO HEALTHCARE AND ENHANCING WOMEN’S ECONOMIC CAPACITY Socio-economic determinants affecting access to healthcare Nepalese society is divided into castes and is still very much shaped by patriarchy. Women are severely restricted in relation to health, education and control of their bodies and life choices. It is often husbands and parents-in-law who make the decisions, including with regard to sexual and reproductive health, while the women are traditionally confined to their maternal role and are limited in their options in terms of developing income-generating activities. Dissuaded from seeking pregnancy and postnatal care, 63%10 of them give birth at home. In rural areas, where they are intensively involved in agricultural labour, women have little or no time for information meetings or sessions on prevention which the community consider to be unproductive.

It is often husbands and parents-in-law who make the decisions, including with regard to sexual and reproductive health (...)

Using micro-finance training workshops to raise awareness about sexual and reproductive health

Doctors of the World has also made available an obstetric emergency fund within the cooperatives, which provides women with money in the event of a pregnancy-related emergency (transport by ambulance etc.).

Supporting women in their desire for independence At the heart of the Doctors of the World programme in Nepal is support for raising awareness about the importance of using sexual and reproductive health services. According to a knowledge test about sexual and reproductive health realised in June 2012, an average of 61% of family decision makers (husbands, mothers in law) attending the microfinance group now know at least 3 danger signs in pregnancy. 58% of them also have some knowledge on neonatal complications and 96% of women, 90% of mothers-in-law and 94% of husbands agree that a woman should go to at least 4 antenatal consultations. Women say that the monthly meetings mean they feel more able to talk about their personal experiences of pregnancy. They all agree that they no longer want to keep quiet about their health issues and wish to put an end to the silence which prevented them from getting on with living their lives.

� Doctors of the World’s partners

Health education and micro-finance training sessions take place monthly and are organised by group leaders who have already received training. Women meet and share their experiences related to pregnancy, antenatal care, contraceptive methods and other issues. Younger women, as well as men and adolescents, can also attend these meetings as observers.

Doctors of the World is working with two national partners to develop and implement the different elements of the project: • the Community Development and Environment Conservation Forum (CDECF), a local organisation in Sindhupalchok, is involved in communities through health awareness campaigns and training on micro-

The section on micro-finance focuses on managing household budgets and expenditure and also covers methods for borrowing and saving money and the distribution of interest which is not reinvested. The loans are essentially allocated to income-generating activities (for the purchase of seeds or farm animals, for instance), but may also be used to pay for medical care. In addition to these monthly meetings, a major health campaign is held annually in each VDC. Health messages are disseminated in the form of song and dance competitions, and medical consultations are available for pregnant women. It is an opportunity to educate groups beyond those involved in the micro-finance initiatives.

finance services. • the Centre for Micro Finance (CMF) provides technical assistance at different stages during the establishment of cooperatives. MdM has also developed a close partnership with Planet Finance which shares its expertise in the field of micro-finance through training, evaluation and advice.

� Cooperatives: an evolutionary process © Stéphane Lehr

Women form small groups within their community and set up income-generating activities with startup capital from MdM. The second stage is for the groups to merge to form centres and these then finally culminate in a cooperative, which will be the

only one in the VDC. Aided by financial support from MdM and technical advice from the CMF, the CDECF ensures that cooperative members receive training in how micro-finance services work.

10. Nepal demographic health survey 2011

Doctors of the World

Press kit 8 march 2013

350 of the borrowers are women and 200 are men. Loans are more likely to be granted to women because they are more honest and make their repayments on time. We set an interest rate of 14% for loans and 8% for savings. The interest rate is decided by the general meeting. The rate of interest for a loan from a wealthy landlord is 24% and it’s 18% from development banks. Before, people weren’t in the habit of saving, but here borrowing and saving are transparent. Gradually the people of Thokarpa are establishing larger businesses. The aim of the cooperative is not only to make a profit but also to organise socially useful activities. For example, we have accounts dedicated to a children’s education project.” Dip Adhi Kari, Director and Manager of the Thokarpa Cooperative

In the past women didn’t pay attention at school and were too afraid to talk about their pregnancy-related problems. As a group leader, I have to persuade them that talking about this subject will help them to find solutions, benefit from healthcare and not suffer. Gradually, through the meetings, interactions are evolving: women share their experiences and talk openly about prolapse, contraception or bleeding during pregnancy, even if there are men present. As a group leader at these meetings, I encourage women to make their voices heard and to exercise their rights. Now women share their ideas and realise that this freedom of speech enhances their capacity. Now it’s them who come to me at the beginning of the meeting to tell me what subjects they want to talk about, saying, ‘We want to find out more, please’!” Laxmi Maya Pajavili, group leader in Thokarpa

Press kit 8 march 2013

STRENGTHENING FINANCIAL ACCESSIBILITY TO SEXUAL AND REPRODUCTIVE HEALTH SERVICES In its work to strengthen sexual and reproductive health services and access to them, Doctors of the World is seeking to support national and international efforts in this area. Simple and effective interventions exist which could prevent the majority of maternal deaths in the world, in particular access to family planning services, high-quality obstetric care and attendance by a skilled health professional at each birth. Unfortunately, access to these services is all too often hindered by distance and/or the cost of services, lack of infrastructure and transport and sociocultural barriers (women lack decision-making power, freedom of movement and opportunity to manage their finances, as in Nepal).

France

Tchétchénie

Pakistan Mexique

Égypte Inde

Haïti

In the Sahel, Haiti, Laos and Ivory Coast, MdM and its local partners are implementing campaigns which aim to remove the financial barriers which can hinder access to comprehensive, high-quality healthcare and can interrupt the continuum of care.

Népal

Mali

Niger

Laos

Tchad

Guatemala Burkina Faso

Nicaragua

Côte d'Ivoire

Somalie

Liberia

Colombie

Kenya Rép. dém. du Congo

Pérou

Angola

Uruguay

Haiti Sexual and reproductive health programme

Programme for pregnant women and children under the age of five. Integration of the unwanted pregnancies issue

Watch the videos et pictures of MdM programs in Nepal, Laos, Ivory Coast and Chad on

Ivory Coast

SAHEL

LAOS

In the region of BasSassandra, Doctors of the World is supporting the health authorities at regional and district level to improve the implementation of free healthcare for pregnant women and children under the age of five.

In Mali (in Koro district, Mopti region), Niger (Keita department, Tahoua region) and Burkina Faso (Djibo district), advocacy at regional level for financial accessibility to women’s health care.

In the town of Champassak, MdM has introduced an innovative approach through a system of vouchers, in order to ensure free access to health services for pregnant women and to empower them to exercise their right to demand access to care.

www.women.medecinsdumonde.org 14

Doctors of the World

Press kit 8 march 2013