Vulnerable Women in Nepal

With towering mountains, Nepal has been a famous destination for the most awe-inspiring treks and many other outdoor activities. However, these spectacular mountains contribute to the geographical constraints for people to get medical care. The impact on the access to medical care by the 11-year conflict, as well as the socio-cultural reasons, also makes women more vulnerable in this setting.

Khotang is a district with a population of around 250,000 located in eastern Nepal. There are no roads and villages are built along the ridges. Around 60% to 70 % of patients from the villages often have to walk over the mountains for at least two hours or even a day in order to go to the Diktel District Hospital, the only hospital in the whole district.

In addition to social, economic and geographical constraints, Médecins Sans Frontières (MSF) assumed that the conflict between the Monarchy and the Maoists would prevent the people of Khotang accessing medical care. MSF started the health support project in Khotang in March 2006, focusing on strengthening the quality of health care in the Diktel District Hospital and setting up quality reproductive healthcare activities.

Custom of delivery at home

To deliver at home with the help of family members, traditional birth attendants, or even alone without any assistance, is a common practice in Nepal, especially in mountain areas. Only 13.5% of deliveries in the country are attended by trained personnel*. Thus the chance of women suffering from pregnancy complications and delay in transferring to hospital is high. Among the delivery cases received in the Diktel District Hospital in the past nine months, around 20% have been pregnancy related complications.

That day, Pramila with her 9-month-old son whom she needed to take care of, were waiting to be transferred to Kathmandu by MSF for fistula repair surgery. And Pramila herself was being taken care of by her crippled father.

Pramila was 27-year-old and was a mother of a daughter and a son. When she gave birth to her younger son at home, she suffered from labour pain for two days. At that time, someone from village health post, who did not have any formal training on midwifery, tried to help her but in vain. Then her relatives carried her on foot for more than four hours to the hospital.

At last, she delivered her son at hospital safely. But later on she found that the urine was involuntarily discharged from her vagina. She was diagnosed as having a vesicovaginal fistula which is the debilitating complications of prolonged labour.

"Because of this problem, I can only work at home, but not in the field," she said. "I need to change my clothes three times a day. It's very inconvenient. I can't work properly. And I feel a slight pain in my abdomen."

Since MSF does not have facilities to support the fistula repair surgery, MSF paid for the cost and transportation to (and later their return from) Kathmandu to refer Pramila to another specialist medical organisation for further treatment.  

Dr Sandeep Mahat, MSF national doctor working in Diktel District Hospital, also recalled a delivery complication case that he handled – a woman with a placenta retained in uterus for 13 days after the delivery.

 "She delivered at the village development committee's health post. Someone tied a knot and a wooden block to the umbilical cord to try to expel the placenta. They also tried many other methods with traditional healers. Lastly she was sent to hospital. It was very stinky. And she was very pale. I don't know how much blood she had lost. We had to treat her for anaemia with blood transfusion. She recovered after staying in the hospital for more than 10 days," Dr Mahat said.

Frequent domestic violence

Low social status also leaves women in a more vulnerable situation. Dr Mahat was still appaled by a serious physical assault case he handled. A 6 to 7-month-pregnant woman was stabbed with knife by her drunken husband. She got 15 cut wounds all over her body, as well as bone fracture and tendon rupture in her forearm.

And around two month ago, there was another abuse case. A 19-year-old woman got pregnant before marriage. Then she married the baby's father but she was not accepted by her husband's parents. After delivery at home, she was deprived of proper food and adequate care until her parents visited her ten days later. Her parents immediately carried her to hospital by one day's walk.

"When she arrived at the hospital, she was semi-conscious and had a toxic look. I would say she was in septic shock," Dr Mahat said. "We treated her with everything we could. She improved a little bit. When she was conscious, she just kept crying and didn't speak. Three or four days later, she died."

Unsafe abortion

Abortion on demand up to 12 weeks pregnancy has been legal in Nepal since 2003. Yet, complications after unsafe or illegal abortion by untrained personnel or in an unhygienic environment is still one of the major concerns on women’s health in Nepal.

"Two to three months ago, there was a woman who had unsafe abortion outside medical facilities. But it was an incomplete abortion and it would cause massive bleeding. When we saw her in emergency room, she totally collapsed. She had almost no pulse or blood pressure. She was very pale. She lost a large amount of blood," Dr Mahat recalled.

"Most of the complication cases after unsafe abortion presented with serious bleeding. After post-abortal care and monitoring in the hospital, all of them recovered," he added.

The situation today

With the signing of the peace agreement and the formation of the interim administration in May 2006, there has been significant improvement in security in the country including Khotang. Khotang district was also less affected during the conflict than other areas. MSF decided to hand over the Khotang project to the Nepali Ministry of Health at the end of August 2007 as there no longer exist the conflict related difficulties for the people to access medical care.

"We believe that the District Health Office is currently in a better position than at any other time to take over the responsibilities from MSF in the hospital, and run and build the health activities in accord with Nepali Ministry of Health policies," said Simon Heuberger, Project Coordinator of the Khotang project. "MSF will continue to monitor the project for at least 4 months after the project closure. And we will assist MoH in the distribution of our drugs and medical materials donation to patients."

MSF has worked in Nepal since 2002. MSF continues to provide basic and secondary health care in conflict-affected Kalikot, in western Nepal.

 * World Health Organisation, Regional Office for South-East Asia, Country Health Profile – Nepal.