A fat and smiling baby is supported on a slab of stone by her mother and encircled by close family. The fair skin of the child reflects in the faces of the father and grandfather. In a month or so the child will have learned the greeting and gesture of “Namaste” and will utter the word with her hands pressed together before her chest. Now she reclines glowing against the grey stone and grey monsoon clouds.
The rain lingered for two days. The air was colder than it had been in Raha. The hotel was a tightly constructed stone building. Outside the ground was saturating and forming mud. Inside most of the space seemed devoted to the storage of rice and biscuits to sell to patrons. USAID bags of rice were stacked at the foot of a bed in one of our rooms. Flies were everywhere. In the night I was jarred awake by the sound of rats working their way through the mud insulated ceiling. A black plastic tarp had been hung from the rafters to catch dirt and other detritus that would fall as a result of the rodent excavation. I barely slept.
The Female Community Health Volunteers (FCHVs) were reticent, and weathered. The focus group with the FCHVs was held in a large open room on the second floor of the hotel. Two small windows and the doorway let in a natural light. A woven plastic mat was placed on the floor for sitting. Conversation picked up after tea was served. Earlier we listened to an FCHV’s account of a mother struggling to survive after an incomplete breech delivery—a massive complication where the baby’s feet came out first, but the shoulders became stuck in the birth canal. With no obstetric care provider capable of handling the complication the woman and her half-delivered baby were carried in a basket for seven hours along the trail to the main district hospital in Dunai. When they reached the hospital they were told they needed to fly the mother to a larger hospital in Nepalgunj where such a complication could be handled. Before the money was raised to buy the plane ticket the baby died. Remarkably, the mother survived the ordeal.
In a region of Nepal where health volunteers fill the role of physicians and travel by foot is challenging for even the young and fit, my mind’s images of women giving birth on the trail, or suffering for days only to face a mortal outcome were confirmed as terrible reality.
In this VDC there was a sense of hopelessness in the stories told by the FCHVs unlike in other regions of Nepal we had visited.
A conjecture as to why this sentiment revealed itself so acutely is embedded in the combination of geographical barriers to care, and a breakdown in the VDC’s local health system. Sahartara is a seven hour walk from Dunai along a rocky trail that at times is flush with the river it follows—a real danger if the river was to swell suddenly during monsoon season. In addition, the village’s own health post is staffed at best once a month by a government employed health worker. These impositions have left the FCHVs in Sahartara to bare a great burden in the care of their community, and they bare it with little support or regular training.
Here, FCHVs have no other option than to counsel expecting mothers to travel to Dunai to give birth. However, this fact is complicated by a cultural inhibition on the behalf of pregnant women to inform someone once labor ensues. The laboring mother now unable to make the trip to a birthing center gives birth at home, or as some traditional practices dictate, outside in the family’s goat shed. Outside, in completely unsanitary conditions, and quite possibly in below freezing temperatures is where many births take place.
In this situation there is a small chance the birth may be attended by a skilled birth attendant, or a Female Community Health Volunteer, but is it more common that an FCHV is called only in the event of a complication—in which case little can be done if at all.
The initial response from the group of Sahartara’s community health volunteers to the proposed maternal and child health project between Medic Mobile and One Heart World Wide was not entirely positive. It became clear from the discussion that while the reminders function of the SIM application seemed useful, the group felt the SIM application would be of little use during emergencies. However, in those instances the phone would be used to call a skilled health worker at the local health post, or in Dunai. It would seem that at the very least an FCHV equipped with a Medic Mobile phone would not feel entirely alone in the face of an impossible situation.
While there was some intermittent cell service in the VDC, the reality is the health post in Sahartara is staffed too infrequently to expect someone to be available in an emergency, and while a skilled health worker could be reached in Dunai, that person is too far from the emergency to be of any immediate aid, other than advice over the phone. The group of FCHVs expressed that they wanted to take on more responsibility—acknowledging their solitary role as care providers in the VDC. Yet, their desire to serve their community seemed to be consistently undermined by forces out of their control.
The group warmed to the idea of reminders to see patients, and alerts about upcoming deliveries. The FCHVs thought that with this function they would be better prepared to bring a pregnant woman to a birthing center before labor began. The project’s focus on antenatal and postnatal care will hopefully allow for community health volunteers to track the course of a woman’s pregnancy. This rapid availability of patient information is crucial in places like Sahartara because FCHVs can then plan ahead to escort an expecting mother to a birthing center while the mother is still capable of traveling.
In the case of the tragic breech delivery, a phone equipped with a Medic Mobile application could have at the very least provided rapid support to the FCHV by establishing a means of direct contact with a skilled medical professional. However, since the proposed project will address the longitudinal care of pregnant women, ideally the breech position of the baby would have been recorded during an antenatal care visit, and the FCHV would have been reminded through the mobile tool to bring that mother to a birthing center prior to her due date to safely deliver her child.
Leaving our conversation in Sahartara it was clear that when something vital like a staffed and operational health post is missing from a community’s health system, caring for a community becomes near impossible for health volunteers who try to fill the gap. Medic Mobile hopes to establish a mobile tool that supports Female Community Health Volunteers in their task of providing care to their community. However, as a humble observer of these meetings and the proposed project, it seems that while Medic Mobile tools are novel, powerful, and potentially quite empowering, the project is a small part of what should be a large and targeted effort to correct inequities in access to care not only in Sahartara, but throughout Dolpa, and all of rural Nepal. Currently, there are real barriers to implementing Medic Mobile’s project in Dolpa such as unreliable cell network coverage, and a struggling government supported health system. Fortunately One Heart World Wide’s mission is to build birthing centers in the region, as well as train and equip skilled birth attendants to create a “Network of Safety” around women and their babies. We left Sahartara feeling deflated and overwhelmed by the severe reality of health care in this region. While we came to discuss solutions we were reminded of our limitations, and that any success would be achieved only through collaboration. Medic Mobile tools are just tools. In order to fully realize their potential these tools require adequate health systems and partners like One Heart World Wide to use them.
Text and images by Lewis Feuer.