Welcome Labour Room

The Story of Maternal Health in Nepal

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Life, death and childbirth in the Kali Gandaki Valley:
The story of Guardian Angels in the Himalayas

She is quiet in a room of chaos and clatter. Tulkumaripun’s small frame sinks into the dark turquoise sheets of the Baglung District Hospital Maternity ward. The bright green of her traditional Nepalese dress blends into the sheets. A new mother, her pained stillness seems out of place. Around her a mob of women in lavender saris gather, young nursing students on placement in the district hospital. Worried expressions cover their normally excited faces, and their chatter lowers to a hushed discussion. Taulkumaripun barely opens her eyes, emitting only a soft moan as the drip’s position is modified. The lavender mob straightens her blankets, and then leaves her to rest.

Doctor Tarun Paudel, the head physician at Baglung hospital explains in the training hall nearby that Tulkumaripun had arrived at the hospital the night before after an eight-hour journey. The young nurses had said she was from Niskut in Magdi district, a couple hours away. Doctor Tarun explained Tulkumaripun’s baby’s hand had come out first during labour, leaving the baby stuck in the birth canal. The family had then carried her down to the nearest road, where they bartered for transportation to Magdi hospital. When they arrived at the Magdi Hospital, the staff immediately recognized she needed surgery, and put her into an ambulance jeep to Baglung, where Doctor Tarun gave her an immediate cesearan section. Janaki K.C., the head staff nurse, chimes in: “She was very lucky.”

Baglung District Hospital provides the major healthcare facilities for the entire Kali Gandaki valley. Doctor Tarun who has worked at the hospital for 13 years explains the hospital needs to serve over 600,000 people in the district and surrounding areas. It is the only hospital in the district with an operating theater.  Sitting amongst the training midwives, he is calm and smiling, seemingly at home amongst the female banter. He chuckles to himself: “You must be a general doctor here; specialists only stay in the city. A Family physician must be multi-skilled. Multi-skilled means everything from geriatrics to infants.” Well attuned to the needs of his community, he has watched the hospital grow from only having 25 beds and himself, as the only doctor, to the now nine doctors on staff.

Janaki K.C. who has been working as a nurse for the hospital for over 25 years adds, “Not sufficient: men, money, and materials.” When asked what poses the biggest challenges for women in the area her well kept face pauses for a moment, listing each complication carefully, as if feeling the weight of their meaning.  “After delivery hemorrhage, post abortion complications, transportation and geographic location, uterus prolapse, obstructive labour, and the failing electricity…are the main issues,” she says. Sipping on her cup of sweet Nepali milk tea, she quickly adds that for babies, the most common complications are pneumonia, diarrhea, and infection. Janaki estimates with the help of the young SBA (skilled birth attendant) next to her, that the hospital receives 100-120 normal cases a month, including vacuum delivery and manual removal of the placenta, as well as, seven to ten emergency cases a month.Janaki smiles grimily, quoting a Nepali saying: “Giving birth is like the fracture of 206 bones.”

Baglung Bazaar is nestled into the foothills of the Himalayas, three hours away from Pokhara, where mountaineers take off in search of the Annapurna range. The same mountains that inspire the breathtaking views and journeys that Nepal is famous for, create unimaginable difficulties for women like Taulkmaripun.

On a small plateau overlooking the bazaar, two hours hike from the bottom of the valley, a small village called Narayanstan is home to an organization trying to change this grim reality. One Heart World-Wide, an international organization dedicated to serving women in their most vulnerable time, is educating local female community health volunteers in life saving techniques and knowledge.The Narayansthan health post sits on the inner edge of the plateau, overlooking a soccer field the local school has created with nothing more then a few metal posts. Beyond the field, the land begins its steep slope into a pine forest and eventually drops off down sheer cliffs. At the bottom of the drop, the Kali Gandaki River rages. A steep path leads down to a small suspension bridge across the river to the small village of Kusma, where villagers can hail local buses to Baglung. This is the journey the women of Narayansthan and villages further up the range must take to seek help from Baglung Hospital.

In a small office above the four-roomed health post, sits Tilkumari Kolpata, 58, her eyes are bright and kind, while the corners of her mouth always seem to be edging into a smile. Tilkumari has been volunteering for 15 years in Narayansthan. When asked why she volunteers, she answers simply: “To serve the pregnant women, children, and newborn baby.” The women in her ward face many challenges. “They all are poor, so they cannot afford to go to Baglung Hospital,” she says. “They cannot pay for transportation…they cannot afford to eat nutritious food.” Recalling a case in her village last year, “there was one breached delivery, the baby died on the way to hospital.” She explained they delayed their trip to the hospital because of money. They could not afford the transportation. “So these are difficult things,” she says.

In a more recent case, she visited a young woman who was four-months pregnant. The young woman works planting and picking millet, “carrying them from here and there.” She had heavy bleeding so Tilkumari advised her to go for a check-up at the health post. Coming to the small health post, “the health worker said if there is heavy bleeding the baby will die, you will lose the baby. They really insisted if you stop (carrying millet), the baby will survive.” With a sigh, Tilkumari proudly reports the young lady “is doing well now.”

Bina Kumari B.K., 31, has been volunteering in Narayansthan S. Namunagow for seven years. “In my village lots of women die during pregnancy, and babies die during childhood,” she says. “I want to serve them, and I don’t want to see the women and children dying.” The women in her village are shy to speak about their diseases and illnesses. She describes their hesitancy to come to the health post for an antenatal check up. “They won’t check because they feel shy to expose in front of male. In their house their husband doesn’t let them go out, and mother-in-law says, ‘oh you don’t have to go for check ups.’ The women don’t have decision-making power. That is the problem.”

Bina works as an advocate for the women within their families. Describing a labour she attended only nine days ago, Bina explains she told the mother when you start to feel labour pain call me and I will take you to hospital, insisting, “I will help you. I will go by myself with you.” The family seemed cooperative, and the mother-in-law agreed to call her when the labour started. The women fell quickly into labour, after coming back from planting millet. “They didn’t have a chance to call me, or get a chance to take her to hospital, so she gave birth at home.” Three days after giving birth the women had, “a really bad fever, a really high fever.” Bina quickly instructed them to seek help from the health post, where the woman was able to receive some medicine. Bina beams, “She is feeling well now.”

Bina experienced the fear many of her patients go through, when fifteen days after the birth of her last child she had heavy bleeding. “It was lots of bleeding and it was all around the floor.” She explained she had a big clot in her vagina. “I was nearly dying. They took me to the clinic; there is one clinic up in a village. If I was not there in time, I would have died. I was unconscious, totally unconscious.” Bina says the health worker from the clinic, Bina was also afraid and said: “I cannot do anything, take her to Baglung Hospital.” He managed to do an IV infusion, giving Bina some energy, and possibly making the difference between her death and her survival.

Back in the same hospital that would save Bina’s life, Taulkumaripun eyes are open. Her head is propped against a small pillow so she may watch over her newborn baby girl, as Janaki K.C. unwraps the newborn from her many colourful layers to check on her hands. The hand that had come first out of the birth canal is bandaged in white gauze; the other tiny fingers are almost blue. Janaki explains the child has cyanosis—lack of oxygen—and will be sent to Pokhara with the mother’s sister, where the child can receive further treatment.

In preparation for transport, Sofia Jhapa, 19, a nursing student from Pokhara, carefully wraps the child in layers of colourful fabric, the tiny face peering back at Sofia’s sweet smile. She places the now double sized bundle into the nervous hands of the mother’s sister, who is escorted to an “ambulance”—a pick up truck with two benches fixed in the back and an oxygen tank stuck in the front cabin. The pick up truck scuttles down the dirt road past the worn posters along the wall of the hospital towards the main road out of the bazaar. The highway to Pokhara hugs the river valley before winding over the range that separates the two valleys. The road is cracked and worn from years of landslides and the heavy rains of the monsoon season. A lifeline for those women who are able to reach Baglung Hospital, as that same road feeds training and supplies into the valley from the larger cities.

Taulkumaripun nearly became one of the 380 women out of 100,000 that will die during pregnancy and childbirth in Nepal this year, according to UNICEFF. That equates to one in eighty women dying from maternal health complications. The women of the Baglung Hospital Maternity ward and One Heart World-Wide Volunteers are dedicated to riding the Kali Gandaki Valley of these grim numbers—they are the guardian angles of this region, protecting one women, one birth at a time.

Story and Video by Kelly McIlvenny.

Welcome Labour Room is the photographic documentation of the challenges women face during pregnancy and childbirth in developing Nepal. To hear from the individuals working to save the lives of women and infants in the remote villages of western Nepal visit the INTERVIEWS section. If you want to know more about the deathly reality of childbirth worldwide visit THE ISSUE section for information on Maternal Mortality world-wide. If this project has inspired you to TAKE ACTION visit the HOW TO HELP section to find out more. To read about the making of the photo film and the experiences of the photojournalist behind this project visit THE MAKING OF section. You can find out all the latest information about the project in the LATEST NEWS section, along with when and where the project will be exhibited. Please do not hesitate to get in CONTACT regarding the project.