By Jennifer Neczypor
Last week, I traveled from Dhulikhel to Dhadingbesi, the center of one of Nepal’s more remote districts, Dhading. One Heart Worldwide has supported the upgrading of many of the health facilities and birthing centers in this area and has also funded training for many local birth attendants, nurses, and other healthcare providers in the region. With the assistance of One Heart’s talented, good-humored field training officer, Malati Shrestha, who gamely put up with my love of walking despite her preference for the bus, I spent the week visiting many of these health centers, observing the physical buildings, performing needs assessments and quality of care analyses, meeting with the skilled birth attendants, auxiliary nurse-midwives, and nurses who provide maternal care, and assisting with skill development as well as providing hands-on patient care. Besides giving me a much-needed break from the hospital politics and incomprehensible hierarchies at Dhulikhel Hospital, this experience also enabled me to form a better idea of the ways in which care is delivered in the more rural areas of Nepal, as well as the many obstacles that birth attendants face when trying to provide quality care in these regions.
On my first full day in Dhading, Malati and I attempted to visit a birthing center in Salyantar, an extremely remote location where One Heart Worldwide has assisted in the construction of a maternity waiting home for mothers who live far from the health post, and thus far from skilled obstetric care. The trip, I was told, would be a four- or five-hour drive along a dirt road. After forty-five minutes of sliding, brakeless, down washed-out trails and bouncing along in the back of a Jeep, where I was packed in beside eight other people, desperately trying to avoid thinking about how motion-sick I was by pretending that I was on the Indiana Jones ride at Disneyland, I decided that “drive” was a rather optimistic term for what we were doing. A few minutes later, the Jeep coughed thickly, gurgled, slammed into a heap of mud, and lurched to a stop, causing all of us to smack our heads on the metal roof. The young man who was driving jumped out and crawled underneath the vehicle, emerging a little while later to announce what we all knew already – that we would not be going any further in that particular car. We all clambered out of the Jeep, assembling on the side of the road to wait for whatever mode of transportation happened to pass next. Sun-weathered old women walked by, carrying heavy baskets full of bricks on their heads, and groups of young boys waved at us as they herded their cows to pasture. A passenger bus struggled up the same hill that had thwarted our Jeep, becoming lodged in the mud not ten feet behind our erstwhile vehicle. The bus’s passengers – men on their way to work, women heading to the market, children in school uniforms carrying squawking chickens with their legs twined together – climbed out and joined us in our wait.
Eventually, another Jeep approached, this one relatively empty. Malati and I enlisted the driver to take us the rest of the way to Salyantar…or so we thought. Due to the torrential monsoon rains of the past few days, what had once been a dirt road had become a mess of puddled water and thick, oozing mud, and the owners of our new Jeep had to stop numerous times to free one of the four wheels from various mucky traps. It was sweltering in the back of the vehicle, and the Jeep’s top and sides were covered with canvas tarps that, according to the block letters emblazoned on them, had originally been provided by USAID for earthquake relief. The tarps shielded us from the morning’s lashing rains but afforded little air circulation, and after a short while, my main concern again became attempting not to throw up. Pale and sweaty, I laid my head down on the backup I was holding on my lap, and eventually, in spite of the vehicle’s rocking movements, the jerking stops, and the sickening heat, I fell asleep.
When I awoke, the car had stopped once again, and I was alone in the back of the Jeep. I stuck my head out of the canvas, thankfully breathing in the fresh air and relishing the rain slanting across my hot face, to find that the back wheels of the vehicle had become inextricably mired in what seemed to be at least three feet of mud. I jumped out to stand beside Malati, and we watched as the driver and his friends attempted to clear the wheels of their sludgy prison. After an hour, it became clear that the Jeep was not about to budge. Calls from Malati’s co-workers in Salyantar revealed that the remainder of the road was in even worse condition and that no buses were leaving the village. The morning rain had cleared temporarily, and the sun was now scorching the backs of our necks, but during the monsoon season, it rains almost every evening, and Malati did not want to risk being trapped for days in Salyantar if we continued further on foot. Instead, we gathered our luggage and began the five-hour hike back to Dhadingbesi, stopping along the way at a small health post called Muralibhanzyang, where we met with the staff midwife and her twenty-two-year-old apprentice.
We interviewed the midwife, who had been attending births for over fifteen years, and discussed training needs and equipment shortages with her and her assistant. The young midwife-in-training, an incredibly beautiful woman with laughing eyes and thick dark hair that tumbled to her waist, told me that she was very proud that she had recently conducted a vaginal breech delivery with good maternal and neonatal outcomes and that she was hoping to attend an SBA training soon. It was a pleasure to meet the two birth attendants, and I thoroughly enjoyed the hours of walking afterward, rambling through tiny pastoral villages, across corn fields, and down mud-drenched hills scattered with Buddhist stupas, Hindu shrines, and errant goats. During our hike, the twenty-six-year-old Malati and I became fast friends and discovered that we had much in common, including the fact that we are both the first-born children in families of two sisters and two brothers each. She described to me the way in which modern marriages are arranged in Nepal, with the parents selecting suitable partners, then allowing their children to communicate with potential suitors on Facebook to determine who they best get along with, and I, in turn, explained the similarly-comedic process of online dating. By the time we returned to Dhadingbesi, stopping in at the mercifully air-conditioned USAID office for cups of coffee, we were thoroughly exhausted, covered in mud, and laughing about our misadventures.
Malati introduced me to two of her friends, Nepali nurses who work for USAID’s family planning program, and we began relating the saga of the mud to them. Despite the day’s joys and newfound friendships, we were all somewhat sobered by the condition of the road to Salyantar, knowing that it meant inevitable, often fatal, delays in accessing care. Late into the night, as I lay awake in my hostel, unable to sleep due to the pervasive heat and the noise of a pack of dogs fighting outside my window, I kept thinking about the piles and piles of impassable mud separating children from schools, patients from health centers, and birthing mothers from trained birth attendants. Separating those who will survive from those who will not.
When monsoons strike and roads are washed out, when buses stop running, Jeeps get stuck, and the drivers of even the sturdiest cars refuse to continue their journeys due to the risk of vehicle damage, how can laboring mothers travel to health facilities? When ambulances in Nepal are forced to traverse steep, muddy, dangerously narrow mountain roads like the one to Salyantar, how often do they become trapped, unable to neither return nor go on, powerless to get patients to the lifesaving care they need? When feet sink deep into sludge, when slippery slopes, rushing water, mudslides, impending darkness, and the threat of natural disasters render roads so hazardous that even the strong, healthy men who typically work in the city centers, only returning to their home villages on the weekends, refuse to treat them, how can the old, the sick, and the women with very young children who remain in the villages during the week be expected to carry a hemorrhaging woman on a stretcher for hours in order to get her to a skilled birth attendant who has access to oxytocin? When the newborn baby of that hemorrhaging mother starts gasping for breath soon after birth, how can his parents possibly hope to get him to a district hospital that is located half a day’s walk away? And even if they do attempt the perilous journey on foot, how often do they simply not make it in time? How many mothers and babies are lost, not because of a lack of knowledge on the part of healthcare providers, not because of a dearth of medications or equipment or skills, but due to simple yet lethal infrastructure problems? How often do inaccessible roads kill mothers and their babies, not only in Dhading, Nepal but in similarly isolated regions all over the world? After my failed journey to the health post in Salyantar, it is clear to me that healthcare providers must work closely with government leaders, policy-makers, community planners, engineers, and other stakeholders to address these infrastructure needs in ways that are practical, sustainable, and, most importantly, life-saving.