Dying for children

Each year 2,500 Nepalese women lose their lives during pregnancy and labour.

A woman gets a contraceptive implant at an outreach camp. Above: an urban clinic.

Sita frowns as she recalls giving birth to her first child on a mat, in a hut, up a mountain. She was living with her husband's family in a village north of Nepal's capital city of Kathmandu. She was 16, scared and bleeding heavily, with only her mother-in-law and a collection of old wives' tales to get her through. "And then," Sita says, "she forced me to eat cow dung." 

Five years ago Sita trained as a community health volunteer. She educates people about the danger of harmful medical practices (such as administering cow dung in cases of excessive bleeding), and promotes maternal health by encouraging pregnant women to access medical facilities. 

Maternal health is the focus of the fifth millennium development goal (MDG5), which aims to reduce worldwide maternal deaths by three-quarters by 2015. Last year, on average, a woman died every minute from complications related to pregnancy and childbirth. Over 99% of these 500,000 women lived in developing countries. More than 2,500 of them lived in Nepal.

Sandwiched between India and China, Nepal is known for trekking and temples, but also for political instability (it has had 19 governments in 20 years) and a decade-long civil war, which it staggered out of as a republic in 2008. Despite this, successive governments have committed to improving maternal health. Maternal mortality has decreased by about 40%, but still every year about 10,000 Nepalese children lose their mothers to unnecessary, pregnancy-related deaths.

"Addressing maternal mortality requires a focus on three things," says Kamala Thapa from Sunaulo Parivar Nepal (SPN), the local partner of Marie Stopes International. "Family planning, safe and legal abortion and medical care during delivery."

Nepal has invested heavily in all three. Family planning services and contraception reduce the number of unwanted pregnancies and are available free at government and NGO clinics. Abortion was legalised in 2002 (an important milestone because unsafe, illegal abortions are a major cause of maternal death). The Aama Programme, co-funded by the UK Department for International Development (DfID) and the Nepalese government, offers financial incentives of up to 1,500 Nepalese rupees (equivalent to £12 or three weeks' wages) to women who give birth in a medical facility. The government has also trained 48,000 health volunteers like Sita to support the national health system, providing a link between hospitals and clinics, and the local community.

"The initiatives are there," says Dr Pathak from the Ministry of Health, "but what is unusual about Nepal is the combination of cultural and geographical factors that deter uptake." KP Bista, director general of the Family Planning Association of Nepal agrees. "What do you see when you look at the number of maternal deaths in Nepal?" he asks. "You see the number of women dying, sure. But you also see poverty. You see the level of education. You see the number of rural health posts and the state of the roads. Most importantly you see the status of women." He is right. A woman in Nepal is 100 times more likely to die from her pregnancy than a woman in the UK.

The majority of Nepalese people live in remote hill and mountain areas, one-third of the population live a four-hour walk from a road. A Ministry of Health report estimates that 80% of maternal deaths occur in these hard-to-reach areas of the country where women's access to medical services is limited by both geography and strict gender norms. 

"What the government says on one level and what happens in the home is very different," says Sarah Sanyahumbi from DfID Nepal. The life of an educated woman in a city is very different to a woman's life in the mountains where many are discriminated against from birth. They are more likely to suffer from malnutrition, less likely to attend school, likely to be married before they are 16 and likely to have little control over their lives or their fertility. "Having children is seen as a gift," continues Sanyahumbi, "and giving birth is not seen as a medical procedure. Changing these attitudes is extremely difficult. The initiatives are great but the next steps are access and ensuring that women know about their right to family planning and healthcare."

This is where volunteers such as Sita play a vital role. More than 97% work in remote and rural areas, and are invaluable in communicating messages between the government, NGOs and the communities. Sita works in collaboration with SPN, a maternal health NGO that reaches some of Nepal's most under-served areas through mobile outreach camps. She encourages couples to visit the camp to receive family planning advice and free contraception.

Strong government policies, expanding NGO services and a network of committed community health volunteers have improved Nepalese women's access to healthcare and contributed to a decline in maternal deaths. But is it sustainable? "What we have in Nepal is a crisis," argues Ian McFarlane from the United Nations Population Fund (UNFPA). "A pregnant woman dies every four hours. Handing out money to mothers, relying on a fleet of volunteers, this is basically crisis management. If we are to make a real difference, we need to think outside the health sector. We need better roads and better education. We need to raise the status of women, reduce domestic violence and we need more trained medical staff." Sita agrees. "Things are changing for the better," she says, "and I am very proud of what I do. But if we are to have a real impact the government needs to train more volunteers and more health workers because we are not reaching everybody that needs us."

Whether or not Nepal will meet MDG5 is uncertain. "But even if it does," says McFarlane, "we won't meet it meaningfully. We might tick the box, but there is no way that we are going to change the lives of the majority of women in this country by 2015."

But every woman reached is another life potentially saved. Manini, a coffee harvester and mother of five children, is recovering at an SPN outreach camp in the village of Sakute near the Chinese border. She has just had a sterilisation operation. "I knew I didn't want any more children" she says. "After each birth I became weaker and labour was more difficult, but I didn't know what to do. Then the community health volunteer told me this family planning camp was coming. My husband is angry but I know this is my right." Sita smoothes Manini's hair back from her forehead and asks her if it hurts. "No," says Manini resting her hands on her stomach. "Actually, yes it does," she laughs, "but it will be worth it".

Alison Buckler -  The Guardian

Photography by: Brian Sokol/Panos