16-22 December 2016 #837

Saving one mother at a time

Safe delivery in a district hospital in remote western Nepal highlights the importance of having trained family doctors
Bikash Gauchan
Theatre of operations: Clinical staff attend to a c-section at Bayalpata Hospital in Achham last week, and the mother’s priceless smile after giving birth to a healthy baby. Nepal’s Maternal Mortality Rate has fallen dramatically since 1990 because of better transportation, lower fertility rates and skilled attendants at birth.

Nepal’s average maternal mortality rate fell from 901 per 100,000 live births to 258 in 2015. This dramatic progress took place despite a conflict and poor service delivery in rural areas. It was achieved by saving one mother at a time in underserved district hospitals across the country.

Among the facts that contributed to this drop was that the percentage of skilled attendants are birth went up from 4 per cent in 1990 to 53 per cent. Other factors included: dropping fertility rates and increased age of marriage due to improving female literacy, better connectivity and transportation. But 258 mothers dying at child birth is still high, especially compared to the European average of 8 per 100,000 live births.

At the Bayalpata Hospital in Achham where I am Medical Director, we came across a delivery case that is representative of the challenges and opportunities we face in reducing the maternal mortality rate further.

Bayalpata is staffed by family doctors and provides free, high quality comprehensive essential primary and surgical obstetric and orthopedic care to people not just from Accham but surrounding districts as well.

Last week, a 23-year-old female was brought into the Emergency by her mother-in-law, sister-in-law and husband suffering from lower abdominal pain and loss of menstruation for nine months.

The family doctor assessed her and confirmed that she was in labour pain with cervix dilated ruptured membrane on the way to the hospital. Obstetric ultrasound revealed that the baby was in breech presentation, and she was in probable need of c-section delivery.

The husband did not like the idea. “She needs to work and if we do surgery it would be difficult for her to work in the fields later,” he said. The family doctor explained that as the membrane had already ruptured, the baby had less amniotic fluid, and that she would be fine even with a c-section.

When he heard this, the husband ran away and didn’t pick up his phone. After waiting eight hours, there were signs of fetal distress, and the doctors could not wait any longer to operate.

Finally, despite concerns on the part of the mother-in-law and sister-in-law that the patient would not be able to work in the fields after an operation, they gave consent for the c-section, and she was rushed to operation theatre. Bayalpata only had one family doctor at the time, and the only anesthesia assistant was on leave.

The family doctor administered spinal anesthesia for the surgery and requested one of the medical officers to monitor the patient while she was scrubbed, painted and draped. He started the c-section and delivered a baby who was passing meconium with some amount found inside baby’s mouth. The nurse and medical officer resuscitated the baby, which cried to the great relief and happiness of the mother, the medical staff and the family outside.

The value of first cry of a new born is so vital that it gives happiness not only to mothers but also to doctors who clinically care them.

This story highlights the importance of family doctors in saving the lives of mothers and neonates in rural Nepal. The significance of training family doctors during their residency in Doctor of Medicine (MD) for c-section so as to reduce maternal and neonatal mortality cannot be underestimated.

The Ministry of Health must create and recruit more family doctors for every district hospital so that the general public can have easy access to c-sections and similar life-saving services at rural hospitals around the clock. Although Nepal’s success in reducing its maternal mortality rate by more than half in the past 15 years is commendable, 258 mothers out of every 100,000 dying at child-birth is still unacceptably high. Staffing rural hospitals with MDs with c-section training is vital saving the lives of more Nepali mothers.

Bikash Gauchan, MD, is Medical Director of Bayalpata Hospital in Accham which is run by Possible.

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