While driving on a highway in one of the most remote areas in far western Nepal, some 1000 km away from the capital city Kathmandu, we noticed a young pregnant woman squatting on the side of the road, accompanied by a man (Figure 1). We stopped the vehicle and approached her.
She was on her way to a health facility by foot to deliver her baby but could not complete her journey due to pain. “My labor started yesterday evening…We walked for 2 hours (in the morning) to reach the highway and for 1 more hour along the highway; can’t walk anymore (due to pain)”, said the 25-year-old pregnant woman who already had a 3-year-old child at home. “We waited nearly two hours for the vehicle; no vehicles are plying (due to fuel shortage). Few packed pickup cabs passed by, but none provided a lift to us”, added her husband.
The driver reversed our car for nearly 700 meters as there was no other option. “This road is too narrow, I couldn’t turn the vehicle; so I moved the vehicle in the reverse gear”, smiled the driver as he reached the woman.
She was moved to a safer place along the road. I introduced myself as a medical generalist and asked for permission to examine her. Nurses who were accompanying us made a makeshift curtain with a bed sheet. On examination, the cervix was fully dilated and she was about to deliver. As the nearest health facility was nearly 15 min drive and another 30 min walk away, it was not possible to take her there. She had already started bearing down in an effort to deliver the baby. I discussed with her husband about conducting the delivery at the scene. As we were travelling for a surgical family planning camp, we were well equipped with instruments. (Figure 2) Nurses disassembled a sterilized mini-laparatomy and vasectomy sets to have our instruments ready and helped to conduct the delivery. Within 10 minutes, she delivered a baby boy without any complications. We tied the umbilical cord with the sterile thread we use to tie the vas during vasectomy. After delivery, she was shifted to a warm area in direct sunlight (Figure 3); their relatives were called to bring the stretcher to take her back home.
“God sent you all to save me and my baby. May the almighty always keep a grace on all of you”, was the first thing she said to us after the delivery had been conducted. “Thank you doctor, without you, I might not have the opportunity to hold the live baby with me”, said the father. “I have not seen a kinder hearted doctor”, he added.
This case is the representative of many women, who are not able to reach a hospital for safe delivery in Nepal. Due to its difficult terrains and landscapes, health care in rural Nepal has always been a great challenge. Although, access to transport is relatively easy in the flat Terai belt of the country, the people in the hills still face a mammoth challenge to have the access to transport, either public or private , , . In some of these areas, a stretcher or “doko” (a couch made from bamboo sticks) are the only means of transportation.
Nepal is one of the countries with high maternal mortality rate (MMR). Although the country has improved dramatically in reducing MMR, Nepal is still far behind the sustainable development goals (SDG) indicators . Literature published on maternal mortality in Nepal showed 90% of maternal mortality occurred in the rural areas; 11%–14% of the deaths occur during transfer to the health facilities , . Delay in transportation is among the three delays recognized by World Health Organization (WHO). Although it accounts for less than 10% of maternal mortality; but it contributes to most of the deaths that occur in the health facilities. Some of these deaths can be prevented with improved transportation facilities .
To overcome the barriers of transportation and promote institutional deliveries, the Government of Nepal started the “Safe Delivery Incentive Program” in 2005 with incentive schemes for transportation of pregnant women to health facilities of up to Nepalese Rupees 1500 (US$ 15) . In addition, the Safe Motherhood program with free maternity care, known locally as “Ama Surakshya Karyakram” was started in the 2009 . Since then, people in Nepal are aware of the free maternity services available through government health facilities. Difficult geographical terrain in the mountains and high hills of Nepal make people’s access to maternity services difficult. Many pregnant women struggle with transportation to health facilities for safe delivery. Due to a lack of public and private transportation facilities, these problems still persist and people have difficulty getting access to proper care in time and many of them end up having unsafe deliveries and even complications on the way to the health facilities.
Pregnant women in rural Nepal still find it difficult to get safe maternity services. All three known delays are important in these areas. Delay in transport often complicates the other two delays; the delay in taking the decision to seek health care services and the delay in timely maternity services. It thus plays an important role in the high maternal morbidity and mortality in these areas. Easy access to transportation to ensure safe institutional delivery services (at birthing centers) in rural Nepal, especially in the mountains and hills is still a herculean task for people.
I would like to express my sincere acknowledgements to my nursing staffs Ms. Manisha Mahat, Ms. Mona Shrestha and Ms. Kalawati Chowdhary, Family Planning Officer of Darchula district Mr. Arun Joshi, our Clinic Aid Mr. Raju Gurung and our driver Mr. Shanker Gautam for their help to conduct the delivery. Without their help, it would not have been possible for me to achieve that result. In addition, I would like to express my sincere thanks to Ms. Pragya Gartoulla and my colleague Ms. Natasha Kalam for their help to make revisions in the manuscript. And special thanks to our client and her husband to provide consent for the case study and for the photographs.
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About the article
Published Online: 2017-08-11
Conflict of interest: Authors state no conflict of interest.
Material and methods
Informed consent: Informed consent has been obtained from all individuals included in this study.
Ethical approval: The research related to human subject use has complied with all the relevant national regulations, and institutional policies, and is in accordance with the tenets of the Helsinki Declaration, and has been approved by the authors’ institutional review board or equivalent committee.