What does a Mother want ? "Is it male?”
New Jersey- I was a new doctor to this remote village in Nepal. As one patient left the room, I was next called to see a pregnant mother and evaluate her pregnancy which was completed to nine months according to the Auxiliary Health Worker (AHW), in the Emergency Room.

She was surrounded in the room by half a dozen of people, everyone trying to tell me that ‘the labor might have started already.’ I smiled at their witty analysis and requested that everyone wait outside, except for the guardian who could give me reliable information regarding the matter.

She had had contractions since early morning and noticed passage of watery discharge three hours earlier. She could feel the heartbeat of her baby. I asked her if she had any records of her antenatal check-ups.

In our research, of the 240 mothers interviewed, 73 (30.4%) had not gone for any antenatal visit and only 25 (10.4%) mothers had at least four antenatal visits as recommended by the National Safe Motherhood Program of Nepal.1

“I have never had any checkups till now.”

My patient smiled shyly and reported, “I have never had any checkups till now. I never had any illness prior to this.” I was stunned. She had taken neither folic acid nor iron and calcium supplements and had had no vaccinations of any sort. Folic acid–iron reduces the risk of the dangerous postpartum hemorrhage. Risk of dysfunctional labor increased with multiple micronutrient supplementation, although preterm premature rupture of membrane decreased. Puerperal sepsis was lower in those receiving folic acid–iron, folic acid–iron–zinc and multiple micronutrients compared with controls.2

Her mother-in-law added that she has been doing very well with her belly so far. In front was me was a young woman aged nineteen, tanned and pale with innocence or ignorance of the grave condition of her pregnancy. It was a full term pregnancy; I could hear the fetal heart sounds, regular and within good range, luckily.

I explained her course and possible outcomes of her state as well as other better alternatives in the light of the limited clinical information I had. Her mother-in-law persisted in having the baby delivered here and only here.

In rural areas of Nepal, the proportion of institutional deliveries is as low as four percent.3 To be frank, they couldn’t afford the referral to a better centre. About 10% of the total population reported illness, 69% of whom sought care, and depending upon the provider they chose, spent between 2.5 to 4.3% of their per capita household total annual expenditure on health care.4

I wished that the case would not get complicated. I was sandwiched between the limitations of my profession and the state of the poverty of the people. They criticized the Primary Health Care Center ten minutes from where I worked, because a woman died there due to bleeding after delivery. “They pulled the baby with a tube and the mother died 6 hours after”, the vigilant Mother-in-Law said. My friend in the PHC recalls, “There wasn’t even enough Syntocin in here, forget about the specialists nearby. The patient family refused referral elsewhere in spite of our persistent pleadings.”

How many mothers die every year?

The Ministry of Health in Nepal has estimated that nearly 4,500 women die every year from pregnancy-related complications, mostly due to lack of skilled birth attendants and the absence of emergency services and equipment in rural health centers in Nepal.5

That same evening, an experienced AHW of the PHC whispered in my ears, “Dr. Saheb! You are new to this place. You have no idea about the consequences if any wrong went with this mother or the child. The whole village would turn upon your back.” I was saddened in my heart to hear of her experience but I had firm belief in this mother’s physical findings and my convictions.

Slowly, the pain increased in frequency and intensity, gradually widening up the birth canal. It was already midnight when she was taken to the delivery room and was started on the required medications. I asked the mother-in-law where the clothes for the baby were. She grinned at me and showed me a piece of torn shawl. I suddenly lost control at this time at this height of unpreparedness for her grandchild’s birth. “Do you think you are here to wrap some vegetables in this shabby shawl?” She thought I was being funny with her.

Thank God ! Mother & Her new Born Child are Safe

The baby was delivered, alive. Female, 2.200 kg, with good Apgar score. That was the moment when I took the deepest sigh of relief. The child was kept warm in towels and placed on the breast.

According a research, the proportion of mothers who initiated breast feeding within one hour of delivery was 32%, between 1-6 hrs was 47% and between 6 to 48 hrs was 21%.6

What does a Mother want? "Is it male?”

The first thing this young lady asked was, ”Is it male?” I looked at her and responded, ”You should feel good that both of you are safe.” Her grimaces showed that having a daughter again was a poor substitute for her safe delivery.

There was a highly significant decrease in proportion of female births for third and successive births. Over the years, there is some decrease in proportion of female births in all three groups. However, it is statistically not significant that there is a practice of sex selective abortions in practice in Kathmandu.7

She looked less interested in breastfeeding that little baby girl. I had never counseled any mother with such details regarding the importance of breast feeding and maintaining the temperature of the child.

No significant events happened to the mother but the child chirped on and off throughout the night. Even the mother-in-law showed less empathy for this nascent infant.  As it was a normal delivery, the patient was discharged in the evening of the next day after a session of counseling regarding post-partum care and the danger signs to watch for in the child.

Health Workers and Villagers’ Perception

“The local people here want guaranteed treatment for every case, even when they present late and in critical condition” says Mr. Pariyan, a local Health Assistant. There were incidents when a nursing home was vandalized to it’s roots because of a case of fracture that was clinically healed within acceptable deformities. “People here believe that it’s only the injections that work for them and so the health workers use their ignorance as a bait”, a senior Health Worker, Mr. Shah shared. “Many people visit our OPD because they are given medicines for free, and most of the cases are of malingering as well”, says Dr. Shrestha, PHC in charge of this place.

The patients here present themselves only after the traditional practices like shamanism and witchcraft have failed. By the time they reach a general physician, their body has already been in the arena for trials and errors by multiple quacks in the more peripheral parts of this country. “We don’t have a qualified physician in this area. People here must turn to permanent local health worker, no matter how little qualified they are”, says Mr. Aryal, a local social worker. Sometimes patients present themselves to the OPD with self diagnoses like Pneumonia, Typhoid, Hepatitis, Cancer, and they want us to prescribe medications, preferably with no lab supports.

What should we do?

It’s real high time to radically raise public awareness and to strengthen the knowledge of local health workers in regards to practicing medicine to help the needy ones. They should be well trained with frequent updates and training workshops. Many organizations that are working to raise awareness in the Maternal and Child Health  field should reach the outskirts of the country as well. Practicing medicine is a service to humanity when blended with honesty, evidence and integration of knowledge.

-Dr. Shashi Sigdel in New Jersey, USA.

Note: Dr. Shashi Sigdel is a MBBS doctor from Nepal. He will be writing on health topic for USNepalOnline.com. He is our Co-ordinator for Health Section at USNepalOnline.com

References:
1) Mullany LC, Darmstadt GL, Khatry SK, Tielsch JM. Traditional massage of newborns in Nepal: implications for trials of improved practice. J Trop Pediatr 2005; 51: 82-6
2) Parul Christian, Subarna K. Khatry, Steven C. LeClerq and Sanu Maiya Dali. Effects of prenatal micronutrient supplementation on complications of labor and delivery and puerperal morbidity in rural Nepal. International Journal of Gynecology & Obstetrics 2009;106: 3- 7   
3) Chandrashekhar T Sreeramareddy, Hari S Joshi , Binu V Sreekumaran, Sabitri Giri and Neena Chuni. Home delivery and newborn care practices among urban women in western Nepal: a questionnaire survey. BMC Pregnancy and Childbirth 2006; 6: 27-30
4) http://www.irinnews.org/webspecial/nepal/50549.asp
5) http://heapol.oxfordjournals.org/cgi/content/abstract/19/4/218-33
6) Nepal D, Jeeva SM, Mishra S, Paul Vk. Determinant of Early Initiation of Breastfeeding in a Tertiary Neonatal Unit. J. Nepal Paediatr. Soc. 2007; 29:74-78
7) N Adhikari, A Ghimire, I Ansari: Gender role and child health care utilization in Nepal. Journal of Institute of Medicine 2008; 30:19-23

Brief Profile of Dr. Shashi Sigdel:
-Bachelor of Medicine and Bachelor of Surgery (M.B.B.S), Tribhuvan University, Institute of Medicine, Kathmandu, Nepal

Work Experiences:
• Aug 2009 – Oct 2009 Medical Officer, Katari Polyclinic Pvt. Ltd, Udayapur, Nepal
• Feb 2008 – Feb 2009 Compulsory Rotatory Internship, Tribhuvan University Teaching Hospital (TUTH), Kathmandu, Nepal
• May  2005- Aug 2008 Health Faculty for National Academy for Medical Entrance Preparation (NAME), Kathmandu, Nepal
• July  2007 – Sep 2008 Health Faculty for National Institute for Multiple Studies (NIMS), Nepal
• Nov   2008 – Present  Secretary General, COLOR, Nepal
• Feb 2007 Co-ordinator, South Asian Regional Conference conducted by Physician for Social Responsibility Nepal (PSRN)
• Apr 2006 Co-ordinator, National Student Meet for “Awareness on Nuclear Weapons ”,  Nepal
• June 2003 Co-ordinator, A Micro – Health Project on New-Born Care, Dhading District, Nepal  
• Apr 2003 – May 2004  Joint Secretary, Nepal Medical Student Society ( NMSS), National Officer for Reproductive Health and AIDS, Nepal

Publications:
Peer Reviewed Original Research Article:
2009     Bhatt V R, Parajuli N, Mainali NR, Sigdel S, Aryal M, Hamal N, Khanal S, Koirala S, Giri S.
Risk Factor of Stroke among Patients admitted in Tribhuvan University Teaching Hospital. Journal of Institute of Medicine [ISSN 1993-2979] . 2009 Apr; 29 (3): 41-44.
Sigdel S, Maharjan R.K, Sigdel M. A Case Report on Boerhaaev’s Syndrome. Journal of NADEM (Nepal Disaster And Emergency Medicine Center), 2009 Jan; 5(1): 19-21.

Books:
2009: Bhatta VR, Rajbhandari S, Manandhar S, et al. (2009). Gastroenterology. In VR Bhatta (Ed.),
A Manual for Independent clinical practice in developing countries (pp. 234-284 ).          Kathmandu, Nepal. Makalu Publication House.
2009: Bhatta VR, Rajbhandari S, Manandhar S, et al. (2009). Renal Medicine. In Bhatta VR (Ed.),
A Manual for Independent Clinical Practice in Developing Countries (pp.  526-554).       Kathmandu, Nepal. Makalu Publication House.
2007: Coauthor, A Comprehensive Book on Health Sciences, First ed. Nepal: Mega offset Press; 2007.
2007: Author, Madhyarat - A collection of Poems (in Nepali and English), First ed. Nepal: Three Star Press; 2007.
2006: Coauthor, Must Know Facts in Health Sciences, First ed. Nepal: Triyuga Press; 2006.

Non- Peer Reviewed Publications:
2006: A Report on District Health Management Field Program:
- “District Health System” Study in Jhapa District, Nepal
- “Epidemiological Study and Five Year Plan on ARI Control” in Dhankuta District, Nepal
- “Critical Analysis in Obstetric Services” in Mechi Zonal Hospital, Bhadrapur, Nepal.
2004: Descriptive study on the role of family in Causation, Progression and Treatment of illness, Kathmandu, Nepal
2003: “Residential Community Diagnosis Field Study in Budhanilakantha Village Development                
Committee, Nepal.

Unpublished Original Research Article:
Aryal M, Mainali N, Sigdel S, et al. “Role of controlling Glucose, Temperature, Blood Pressure in patients with Stroke presenting to Emergency Department”  of Tribhuvan University, Teaching Hospital (TUTH), Kathmandu, Nepal

Training/Clerkship/Presentation:
• Jan 29, 09 - Feb 2, 09: Research Methodology Training Workshop, Institute of Medicine,  Maharajgunj          Campus, Kathmandu, Nepal
• Sep 13, 2008: Basic Life Support and Emergency Procedures, NADEM ( Nepal Disaster And Emergency Medicine Center), Kathmandu, Nepal
• 1st May,06 - 15th May,06: Neonatal Training Package, Dept of Pediatrics, Tribhuvan University, Teaching Hospital (TUTH), Kathmandu, Nepal
• Feb 20, 06: A Paper Presentation on “ Children Amidst the Maoist Conflict” on 6th International Students Meet, IPPNW, Patna, India

Management activities:
• 2008, 07: Coordinator, General Health Camp organized by Nepal Medical students’ Society, Nepal.
• May 21, 2006:    Coordinator for Health Camp, Kavre Health Society, Kavre District, Nepal
• July 16, 2005: Master of Ceremony, 25th MBBS Day organized by Nepal Medical Student Society, Kathmandu, Nepal
• 2005, 06, 07:    Editor, A Short Review of Health Sciences for Medical Entrance Preparation, published b y Tri-Star Publication, Kathmandu, Nepal
• 2004,07,08: Editor, Medicamomentosa, a yearly graduation issue of Nepal Medical Students Society (NMSS)
• 2003: Editor, Kasturi, a tri-monthly magazine of the Nepal Medical Students Society.
• 2000-2002: Co-0rdinator First Aid Club, Gandaki Higher Secondary Boarding School, Pokhara.
• 1997-1999: Nepal Junior Red Cross Circle, Gandaki Higher Secondary Boarding School, Pokhara.

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