Gitanjali Pradhananga
Delivery is best under taken with the assistance of health professionals in health care facilities like hospitals, health posts, private clinics or nursing homes. This is because qualified, trained and experienced health professionals like doctors, nurses, auxiliary nurse-midwives are capable of dealing with a retained placenta, inducing or accelerating labour, performing a Caesarean section delivery for prolonged labour, detecting a dead foetus and giving a blood transfusion for surgical interventions or post-partum bleeding.
However, in Nepal, decisions about where to deliver and which place to go for delivery are not made during pregnancy but only after the onset of labour. It is this time of suffering which helps family members to decide where pregnant women should deliver. Some women go to the tap to fetch water and end up giving birth there. So why is it not decided in advance where they should give birth when they are not in labour?
During labour, it is the husband or in-laws who usually make decisions about where to deliver because women in labour are in pain and, hence, they are unable to think clearly to arrive at such crucial decisions. Only those women who can afford to go to hospitals or clinics are able to make well-informed and independent decisions without waiting for the approval of the husband or household head. Some wise women even do not wait for the husband or in-laws to tell them what to do because they are the ones who are carrying the pregnancy and know what it means.
Majority of the women in Nepal, however, don’t take decisions on their own and rush to the health care facilities only when they are due. Pregnant women in a patriarchal society like ours have no say if the in-laws decide - for better or worse - that in the best interest of all, they should give birth at home. More often than not, delivery charges at a facility are high, and most of the time, families can hardly afford these fees as they are estimated to cost approximately three months’ income of a poor household for a normal birth and six months’ for a Caesarean section.
Added to this is our country’s challenging terrain and poor communication network, meaning that travel to referral centres is not only difficult, as it involves several hours of travel by road in addition to travel on foot, but also expensive, accounting for as much as 60 per cent of the total cost associated with a normal delivery in Nepal. This is not surprising as the average time spent in reaching a facility is estimated to vary from a mean of 2.8 hours in the Terai districts to 8.3 hours in the mountains.
In rural Nepal, the closest health facility are the 3,132 health posts, which are often not equipped with drugs, supplies or personnel for obstetric emergencies. While human resource availability is still a constraint at the health facilities in the rural areas where 83 per cent of the population lives, more serious is their unequal distribution with most doctors, nurses and midwives all concentrated in Kathmandu and other cities.
The attitude of the nurse/mid-wife at the health care facilities is another reason why pregnant women do not necessarily seek professional obstetric care. Although the efficacy of modern obstetric care and reliance on the ‘expert system’ are universally acknowledged, the attitude of the nurses or midwives, in general, are a constant source of concern and discomfort for all. For they have a tendency to shout at expectant mothers for presenting late and sneer at those who are poor. They embarrass pregnant women by telling them that they are filthy and even slap them when they delay in pushing during the second stage of labour. At times, they do not hesitate to leave pregnant women unattended in the ward. Though uneducated, expectant women are not that stupid to know that hospitals are short staffed and nurse/midwives overworked. Yet this does not necessarily mean that the midwives should be unsympathetic or irresponsible.
Sometimes, the midwives do not come quickly when pregnant women call them for assistance. Some do not sit in the ward, leaving pregnant women on their own even when babies are coming out. In a situation like this, expectant mothers deliver without any health professionals around, making them feel that it would have been better if they had delivered at home where they could at least get care and support from the family and community, if nothing else.
As a matter of fact, all that expectant mothers expect and need is assistance when in labour, and they reckon that they do not necessarily have to go to a health care facility for delivery. Nor does every woman have delivery complications to require delivery at a health care setting. It is basically for these pregnant women that informal service providers like traditional birth attendants come to the rescue. Indeed, these attendants are often a preferred source of treatment because they live in there and are always prepared to help in the community. Nor do they charge as much as the health facilities do. In fact, they have flexible fees, do allow credit and payment in kind. These traditional birth attendants often make home visits, which the skilled birth attendants normally hesitate to do because most often they are non-local females.
Traditional birth attendants are not that difficult to deal with either because they treat pregnant women with dignity and respect and provide privacy of their own. Above all, these attendants know for sure that the midwives would go mad if they delayed referring pregnant women to the health care facilities should obstetric complications arise. In the event of complications, traditional birth attendants do refer women to an appropriate health care institution and try their best to save mothers’ lives.
No wonder then that most pregnant women in Nepal prefer to deliver at home assisted in labour mostly by traditional birth attendants and untrained attendants like female relatives and friends. Unfortunately, when births take place at home, families do not have capacities to respond effectively if and when obstetric emergencies occur. And obstetric emergencies do occur as a result of a number of complications such as haemorrhage, eclampsia, obstructed labour, sepses and the complications arising out of unsafe abortion.
It is estimated that 15 per cent of pregnancies are likely to develop serious complications and that they account for as much as 70 per cent of the maternal deaths in our country. These deaths can be averted if pregnant women have access to good quality emergency obstetric care in health facilities for the management of complications arising during pregnancy, delivery or the post-partum period.
Prompt treatment
Access to emergency obstetric care in the health facilities does not necessarily mean that complication can be predicted as there is risk of complications even in well-nourished educated women receiving adequate antenatal and delivery care. What this means is that obstetric complications can be identified and treated promptly in order to avoid most maternal deaths.
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