A report on

Women's healthcare survey

Rachael Gentile, April 2009

In March 2009, The Kangchenjunga School Project organized a volunteer trek to visit a number of small villages in the Kangchenjunga region of Nepal. One of the aims of this trek was to gather information on the level and amount of healthcare the residents of the villages were receiving with an emphasis on maternal healthcare. The Kangchenjunga School Project has been involved in promoting education, health, and environmental sustainability in the Kangchenjunga region for 20 years. The organization is well known and respected in the area. As a result, the organization and its members are well received and trusted in the villages, putting them in a unique position to collect information on healthcare. The following are observations about the current status of healthcare in the villages, along with reccomendations for ways to improve the healthcare and lives of the residents.

This report covers the villages of Sinam, Tellok, Mamankhe, Hellok, Phole, Gunsa, and Lelep.

Sinam

In Sinam, the two most apparent factors that inhibit women from receiving healthcare are distrust in the local midwife and lack of education. Although Sinam does have a resident midwife, many of the residents do not use her services. All of the women we spoke to felt that the midwife was unknowledgeable and that they were better off seeking out the help of friends and family when they went into labor. Most of the women in Sinam are not receiving any prenatal, perinatal, or postnatal care, as a result of this attitude toward the midwife. Women who have any abnormal or high risk pregnancies are left to their own devices causing both them and their babies greater risk for illness and death.

One woman we spoke with in the outskirts of Sinam has had six children and has never had a prenatal exam or used a midwife. She was fortunate in that her first four children were born without any complication; however, in her last pregnancy she went into labor and unexpectedly delivered twins. She described the birth as very scary, difficult, and painful. She explained that the first of the twins was born fine but the second child would not come out (presumably because the umbilical cord was wrapped around the child). Eventually the second child came out and was healthy, but it took the woman a long time to recover from the labor. When we asked the woman why she did not have a prenatal exam she looked confused and said that she did not know why. If this woman had been more educated about the need for prenatal exams and had access to a knowledgeable and trustworthy midwife, the birth could have been much less painful. This woman was incredibly lucky, as both she and her baby ended up fine. Not all women are so lucky and in the worst cases the mother, child, or both may die because of inadequate maternal healthcare.
There also seems to be a lack of proper education about birth control in Sinam. It is clear that most of the women understand the benefits of family planning and having fewer children, but they have many misconceptions about how the various types of birth control will affect their health. A number of women we spoke to believed if they took birth control pills the pills would stack up in their stomach and eventually kill them. Many women of Sinam also believed that injections of Depo Provera would somehow lead to death. Because of these misconceptions, many women in Sinam do not use any form of birth control or practice family planning.

We did encounter a few women whom we believe may be using a form of birth control in secret. One woman we met has only had two children and they are four years apart. Her husband lives at home and she said that she does have sexual relations with him regularly. She claimed that she did not use any form of birth control but got very quiet and shy when we asked her about it. Unfortunately, when we asked her there was a crowd of people around and she may not have felt comfortable telling us the truth. We later asked another woman about it and she said that some women take birth control in secret because their husbands think it is unhealthy and do not want their wives to take it. This can obviously put a large amount of strain on marriages.

I have two recommendations for improving the health and wellbeing of the women of Sinam. First, the resident midwife should be retrained or trained further so that the women of Sinam feel that they can trust her. After her training the situation should be reassessed to see if more of the women are using her services. If they are not, the midwife may need to be replaced by someone who is more effective. Second is to educate the people of Sinam about the importance of prenatal care and correct the misconceptions they have about the dangers of birth control. This could be accomplished through small group discussions led by the midwife or through presentations on maternal health and family planning.

Tellok

In Tellok most women seem to be getting at least a minimal amout of healthcare. Tellok has a health post with four healthcare workers who each had two years of training in Biratnagar in both maternal and general healthcare. The healthcare workers provide care to women both at the health post and in their homes. In general the women who are more educated tend to receive more prenatal care because they go to the health post for it; however, the healthcare workers do try to go to the homes of pregnant women who are not coming into the health post to give them checkups and educate them about the benefits and importance of prenatal care. The women who do get prenatal checkups come in between one and five times before they give birth. On the first visit all women are given iron supplements and worm medication. On all subsequent visits the women are given additional iron supplements.

When women go into labor they can choose to come to the clinic to give birth or stay at home and have the midwife come there. Most women seem to prefer to give birth at home; last year only 6 out of 105 births occurred at the health post. If there are any serious problems during birth or the midwives notice a high risk pregnancy, they send the women to Biratnagar to be cared for by a doctor.

Most women we spoke with practice some type of family planning and they seem to be well educated about the different forms of birth control. The most common types of birth control used are pills and Depo Provera. The healthcare worker estimated that only about ten percent of the women in the area do not use a form a birth control. Many of these women are not using birth control because their husbands are away, working elsewhere so that they can send money back to Tellok.

The health post in Tellok also provides decent general healthcare for the residents. It is larger than many of the surrounding health posts so people from other areas often come to Tellok when they have more serious health problems. Similarly to maternal care, the healthcare workers will treat people both at the health post and in their homes. Providing treatment at home will sometimes require health workers to walk for an entire day to get to the patient. The health post has a vaccination fridge; however, it was not working when we visited. Because the fridge was not working the healthcare workers had to figure out what vaccines they needed, go to Taplejung to get them, and then give the vaccines immediately.

According to the healthcare worker the main health problems she sees are anemia and malnutrition. She is trying to help reduce anemia in pregnant women by giving them iron supplements, but because of the poverty in the area she cannot do much about the poor nutrition of her patients. The poverty in the area is also one of the factors that leads to what in her view is the biggest problem they face: finding healthcare workers and doctors who are willing to work there. In addition to the poverty, the healthcare workers have to work very hard and to walk long distances to see patients, and they are poorly compensated for their work. As a result of thse conditions, the village has not been able to get a doctor to work there, which forces patients with severe health problems to go to Biratnagar.

My recommendations to improve the healthcare in Tellok are to improve the agriculture in the area and, if possible, try to recruit a doctor to work there. By implementing a project to improve the agriculture in the area, both the nutrition of the residents and the economic conditions in the town would be improved. If the economic conditions improve recruiting a doctor should be easier. Other ideas for encouraging a doctor work in Tellok are to increase the salary (which is currently being paid by the government) or to provide funding for a resident of Tellok to be trained as a doctor on the condition that he or she returns to Tellok to work.

Current healthcare workers in Tellok:
• Kawshyalla Thapa (auxiliary nurse midwife)
• Bramha Dev Yadav (auxiliary health worker)
• Sushila Karki (auxiliary nurse midwife)
• Rali Maya Thewe (village health worker)
• Chatur Man Limbu (peon)

Mamankhe

In Mamankhe, we noticed three major issues that are detrimental to the health of its residents. The first two are similar to the problems we noticed in Sinam: lack of education about the importance of prenatal care and family planning and poor reception of the midwife by the people. None of the women we talked to in Mamankhe had ever had a prenatal check up and only one of the women we spoke to practiced family planning: she was on Depo Provera. Additionally, all of the women said that the midwife was not present during the births of any of their children. The women all chose to have family members help them with the births rather than the midwife. Interestingly, all of the women we spoke to in Mamankhe also said that they had a witch doctor present when they gave birth, which suggests that they may value the skills of the witch doctor more than the midwife.

The third issue is that the midwife seems to be absent from Mamankhe often and there are no other healthcare workers; therefore, when she is gone, the people of Mamankhe have no one to go to when they have health problems. The midwife was not present when we visited the health post; we were told that she was gone to get additional training (she previously had 18 months of training). There was a peon at the health post, but the only care he said he could give was medication for headaches, fevers, asthma, tonsils, and rehydration. If patients came in with any other health issues he had to refer them to Tellok.

Not only is this third problem an issue itself, but it is probably also adding to the first two issues. In rural communities such as Mamankhe, it is usually the midwife who is best suited to help educate the other women of the town about family planning and prenatal care. If the midwife is absent and/or does not make an effort to improve the education of the women she is working with, then many women will never receive any education of this kind. When we spoke with the peon, he did say that the midwife had a presentation that she brought around to show women about family planning and maternal health. However, as stated before, the women of Mamankhe showed no signs of this type of education and because the midwife was not around we could not ask her about the educational methods she used. Although the educational tools the midwife uses may be adequate, if the women of the town do not trust her opinion (either because she is absent often or just poorly trained) they will not be very receptive to the information she tries to give them.

On top of all of the other issues surrounding healthcare in Mamankhe, the health post has a number of problems with the vaccine fridge. First, according to the peon, the fridge is in a bad location and he often has to deal with landslides that are damaging the building and people trying to break into the building. The fridge needs to be moved to another location, but more importantly, the fridge is not currently working. Lotus Energy, the company that installed the fridges in 2000, should be going to Mamankhe soon to both move and fix the fridge. For the time being, they have to take a cooler to Taplejung to get the vaccines they need and then the midwife gives them out as soon as they arrive; of course this process only works when the midwife is actually there.

I have two recommendations for improving the healthcare system in Mamankhe. The first is to have another trained healthcare worker or midwife in Mamankhe so that someone is always there for the people to go to if they need healthcare. The two healthcare workers will need to work out their schedules so that they do not both leave at the same time. The second recommendation is to impress upon the midwife the importance of trying to become involved and trusted in the community so that she is better received by the people and can then better help improve health and education of the people. If the midwife fails to do this, she may need to be replaced.

Current healthcare workers in Manankhe:
• Ganga Kumari Giautam (midwife)
• Narad Mani Bardewa (peon)

Hellok

There is virtually no healthcare in Hellok, including maternal healthcare. We talked with many women in Hellok and none of them practised any form of family planning, they had never had prenatal checkups, and none had ever had a midwife present when they gave birth. There is no health post, no healthcare worker, and no midwife in Hellok. When people in Hellok get sick they have to walk a day or two to Lelep, another town that does have a health post, to receive healthcare. Many of the women we talked to said that they will only walk to a health post if they or their children are very sick because it is so far and expensive. Therefore, most ailments in Hellok go untreated. Even those who do make the choice to walk to a health post are often no better off either because the health post they walked to is not very good and did not give them adequate treatment or because it is too difficult for them to go back for a follow up if needed. Here are two examples of people we talked to with significant health problems that are going untreated because of a lack of a healthcare system in Hellok:

(1) A thirty five year old woman we met has been having severe pain in her lower right abdomen ever since the birth of her third child six years ago. She has not had a menstruation since the pain began and she gets a burning feeling every time she walks or lifts anything. When it first started she went to the health post in Lelep and they gave her some type of medication in a liquid gel cap, but it did not help. She has not gone back to the health post because it is too far, too expensive, and she does not think they will help her because they did not help the last time she went.

(2) We met a young mother and her child who had a severe skin problem covering most of the left side of his face including his ear. The child looked about 2 years old and seems otherwise healthy. His mother said that it started out as blisters around his ear and then they popped and became open wounds. It looked infected and the area was not clean or covered up. The child was also picking at the area with his dirty hands. His mother said she brought him to the health post in Lelep but they only gave her some type of powder to put on his skin and it was not helping. As with the previous woman, she was very hesitant to go back to the health post for the same reasons.

Not only does Hellok suffer from a lack of a healthcare system, but the women are also very uneducated about maternal health. None of the women knew that they should be getting prenatal exams and they were unaware of other aspects of maternal health such as proper diet and rest. In fact, when we were talking with a group of women about the harmful effects alcohol can have on a growing fetus they all said that they actually drank more while they were pregnant and had no idea that it was bad. Although the women were uneducated about maternal health they were very receptive to learning about it. We gave two presentations while we were visiting Hellok and many women not only came to listen but took turns reading off the slides for one another, asked questions, and showed a general interest in the topics we discussed.

Owing to the very poor healthcare the people in Hellok are currently receiving, I strongly recommend establishing a health post in the town and training a healthcare worker or midwife, or both, to work there. The healthcare worker/midwife should not only treat health problems, but should also develop a way to help educate the people in the town about health issues, especially maternal health.

Phole (Folay)

In Phole, there is a health post and it seems to be well equipped with medicines and educational material. Unfortunately the healthcare worker was in Kathmandu getting more medicine when we came through, so we were not able to meet with him at the health post; however, we did cross paths with him while walking out of the area and were able to talk with him briefly then. We were told that the health post in Phole is funded by the Tibetan government and that it provides the healthcare worker with money to buy supplies in Kathmandu. There is no midwife or another healthcare worker in Phole, so when the healthcare worker is away the people have to go to Gunsa (less than one hour's walk) for care.

Most of the women in Phole use some form of family planning, most commonly Depo Provero. The women we spoke with in Phole either got the Depo Provero shots from the healthcare worker in Phole or they went to the midwife in Gunsa to get them. Most of the women in Phole do not have prenatal check ups. The women we spoke with told us that they did not have checkups either because of shyness or because they never have in the past and nothing has gone wrong. Most of the women in Phole also do not have a midwife or the healthcare worker present when they are giving birth for the same reasons. We were told that the few women in the town who do have prenatal checkups go to the midwife in Gunsa where they can receive free care. The women also told us that if something did go wrong durring childbirth they would call the midwife in Gunsa for help.

The midwife from Gunsa came down to Phole while we were there and we were able to speak with her about the care she gives to the women in Phole. She said the she gives Depo Provero to 14 women in Phole and she confirmed that most of the women do not have prenatal checkups or use her help durring child birth. However, she said that she tries to encourge the women and even holds meetings with the women in Phole every 4-5 months to try and educate them about womens health and the importance of prenatal checkups. This information was very encourageing to hear, but unfortunately we recieved conflicting informaiton from the Phole healthcare worker when we met him. He informed us that the midwife doesn't come down from Gunsa to give care to the women of Phole nor does she hold informational meetings with the women.

Overall, healthcare in Phole appears to be adequate and the women seem to have enough access to maternal healthcare. Unfortunately they are not using it because of lack of education. Therefore, my reccomendation for Phole is to increase education about maternal health and the importance of prenatal checkups. The first step in accomplishing this needs to be finding out exactly what the midwife in Gunsa does to care for and educate the women in Phole, and then steps need to be taken to either increase her involvement or train a new midwife in Phole so that the women receive more care and education.

Ghunsa

The healthcare in Gunsa seems to be better than most of the surrounding areas. The health post is well stocked with medications and it has three healthcare workers: one fulltime healthcare worker who remains in the village year round, another who is only there for part of the year, and a trained midwife. Between these three, there is always someone the residents can go to if they have a health problem. Most of the health problems that occur, such as fevers, stomach pains, colds, wounds, and sore throats, can be taken care of by the healthcare workers in Gunsa. If a resident has a more serious health problem the healthcare workers will refer them to the nearest hospital.

The womens health in Gunsa is also very good. All of the women use some type of family planning (most use depo provero) and they tend to have fewer children than women in the surrounding areas. Most women do not have the midwife present when they give birth unless something goes wrong and only a few have prenatal checkups. However, both the women and the healthcare workers said that women don't usually have problems with childbirth. This may be in part due to the fact that they have fewer children and in general they have a healthy community. One disconcering thing we noticed was that the midwife did not have ergometrin. She said that because she has never needed it the government does not give it to her.

The health post in Gunsa is also equipped with a working vaccine fridge. The healthcare worker has very accurate records of the vaccines she gave and keeps track of the schedule for giving out the vaccines. The healthcare worker told us that all of the children in Gunsa are vaccinated at a young age. It is a bit unclear where and how the health post in Gunsa gets the vaccines. The healthcare worker in Gunsa told us that she gets them from Lelep. According to her, once a month she sends out a carrier who will go half way to Lelep where he is met by a carrier from Lelep. The carrier from Lelep gives the Gunsa carrier the appropriate vaccines to bring back to Gunsa. We got the impression that this system was working quite well until we spoke with the doctor in Lelep who gave us conflicting information. He said that he did not send any vaccines to Gunsa because he has to have permission from the government to give any medication to other health posts. According to him, the Gunsa health post does not send in their health records to the government and therefore the government will not give Lelep permission to give Gunsa medications. This conflicting information is very worrisome.

Based on this information, I have two recommendations for Gunsa. The first is that the midwife in Gunsa should be equipped with ergometrin. Whether the midwife can simply ask for some when she gets her supplies or if the government needs to be petitioned is unclear. Either way, she should have a supply in case of an emergency. The second recommendation is to sort out the situation with where Gunsa gets its vaccines from. It needs to be made clear to the healthcare workers in Gunsa if they should be submitting their health records to the government and how and where they are actually getting the vaccines from needs to be cleared up to ensure that the health post is in fact getting the vaccines they need.

Lelep

The health post in Lelep was the largest health post we saw. There was a trained doctor who worked there and the health post was well stocked with medicine and seemed to keep accurate records. The doctor could take care of most illnesses and injuries in the health post including some very minor surguries. The health post also had a working vaccine fridge and an abundance of educational materials on women's health. The doctor said that he tries to educate the women about maternal health and he also has a number of female volunteer healthcare workers (not trained healthcare workers) in the areas his health post serves that help to educate the women. These volunteer healthcare workers can also be called on when people have very minor health problems and some even help with child birth.

There is no midwife in Lelep and most of the women give birth at home with the help of family and friends. However, most of the women do have prenatal checkups with the doctor and seem to be much more educated about maternal health than women in the other areas had been.

There do not seem to be any glaring problems with the healthcare in Lelep when there is a doctor working there. However, the biggest problem that Lelep has is that there is not always a doctor working in the village and there are no other healthcare workers that can care for the residents. The doctors who work in Lelep are under no contract to stay for any period of time. As a result, there are often gaps (sometimes years) between when one doctor decides to leave and a new doctor is found to work there. During these gaps many health problems go untreated, children go unvaccinated, and if residents do have a serious health problem they have to travel a far to another health post or hospital for care.

Based on this information my recommendation for Lelep is to train a healthcare worker or midwife who will live and work in Lelep perminantly. The midwife could treat health problems and give vaccines to children when there is no doctor living in Lelep. This will prevent the gaps in healthcare that the residents of Lelep have experienced in the past. The healthcare worker can also help to assist the doctor when there is one living there.


As made clear from this report, the healthcare in the Kangchenjunga region of Nepal is lacking in many areas. Overall lack of education and access to basic healthcare and healthcare workers are the factors that most directly negatively impact the lives of the people in this region. It is essential to the health of the people and gowth of the region that these inadequacies be addressed. It is also clear, from the work and succsses of previous projects in the area, that implementing programs such as the ones mentioned in this report can dramatically improve the situation in this area. Action must be taken now to ensure that the health and standard of living improves for future generations.

Rachael Gentile, April 2009.