Yesterday I spent the morning observing Urmila, an ANM who conducts all of the exams at the antenatal clinic (ANC). Over the course of the morning, I was struck by how different the experience pregnancy and delivery is in Achham compared to the United States.
Urmila (ANM) and Dhansara (ANM) in the ANC clinic
In the United States, prenatal exams usually include an ultrasound as soon as the fetus can be seen, the mother is asked if she would like to know the sex of the baby, and the mother and father are often able to hear the fetal heart beat. Deliveries nearly always take place at the hospital, and most mothers need to travel only a short distance to reach their doctors.
Here in Achham, Mothers must walk hours, or even days to reach the hospital for their four recommend antenatal visits. The father is rarely present, and instead of experiencing joy seeing their baby for the first time, many women seem nervous to be in an unfamiliar place. In order to increase the percentage of women coming to the hospital for deliveries the government has created an incentive program, awarding 400 rupees to mothers who have received all four recommended antenatal checkups. Unfortunately, the lack of an electronic system makes keeping track of such data difficult.
Even when women do decide to come in to the hospital, the services they receive are very different from what we have come to take for granted in the US. Although Bayalpata does have an ultrasound, it is most often in use in the inpatient department, so Urmila must do exams manually to determine that the mother and child are well. She is very skilled, but there is no doubt that the use of an ultrasound could improve patient care, and no hospital in the US would be considered well equipped without one. When an ultrasound is performed, the sex of the child is usually withheld from the mother for fear that she may choose to have an abortion based solely on the sex of the fetus.
Urmila and Saguna observe as Dr. Tewari performs an ultrasound in the IPD
At the end of my time observing in the ANC, I was also confronted by the potential dangers of giving birth outside of a hospital, as so many mothers do here in Achham. One of our mothers, whose care has been funded through the online crowdfunding platform Kangu, came in for her fourth antenatal visit midway through the morning. She thought all was well and that she would be able to return home, but she was informed that she was already 1.5cm dilated and beginning the process of labor. Unfortunately, when Urmila completed the exam it became clear that the baby was in a breech position, with its butt coming out first, adding many risks to the delivery. Luckily, the mother was here at Bayalpata and we were able to admit her, and eventually arrange for her to be transferred to Mangelsen, the nearest district hospital, for a Ceasarean section. She has yet to leave Bayalpata, but I hope things will work out well.
Saguna and Urmala doing the paperwork to have the mother admitted
This story is both heartwarming and frustrating. I was glad to know that the mother had come in to the hospital instead of experiencing a difficult and potentially lethal breech birth at home. However, I was also deeply frustrated as this experience highlighted one of the main challenges Nyaya Health has been facing in recent months as we try to implement surgical services (including c-sections) here at Bayalpata for the first time. We have been well equipped for months, yet every day there is some new barrier to completing a successful surgery. Today in particular, we had discovered that the auto-clave was not working, and therefore the necessary equipment couldn’t be sterilized. I look forward to seeing Bayalpata conduct its first successful surgery in the coming months.