A Nurse in Nepal: Determining Quality of Postnatal Care in the Foothills of the Himalayas
A Nurse in Nepal: Determining Quality of Postnatal Care in the Foothills of the Himalayas
Currently in Nepal, the infant mortality rate is 39 per 1,000 live births, and the maternal mortality rate is 170 per 100,000 live births (UNICEF, 2011). In comparison, the infant and maternal mortality rate in the United States is 6 and 21, respectively. Nepal, a poor country with a Gross National Income per capita of $400, compared to the U.S. at $52,300, has far fewer resources to provide maternal-infant care. However, Nepal is committed to providing the best care it can. Recently, the focus has been on prenatal and labor and delivery care. However, the first month after delivery continues to be a risky time for both mother and infant. This time period, from twenty-four hours after birth to six weeks, is called the newborn period for babies and the postpartum period for women. Together, this is the postnatal period. According to the World Health Organization (WHO), there is very little data globally on postnatal care, and it is likely that many women do not receive optimal care (WHO Packages of Interventions, 2010). Researchers are now beginning to study women’s experiences of postnatal care, and I was interested in contributing to this work.
Nepal is well known for its diverse landscape: the Himalayas are home to the world's tallest mountains, while the southern plains boast a hot and humid climate. Kathmandu and Pokhara are the two largest cities and popular tourist destinations.
As a senior nursing student at the University of New Hampshire, I have always had a passion for helping others, an interest in research, and a desire to learn more about the lived experiences of people in other cultures. With the support of a grant from UNH’s International Research Opportunities Program (IROP), I spent nine weeks in the summer of 2013 investigating how women and their babies’ postnatal care compared with the standard set forth in WHO Packages of Interventions for Family Planning, Safe Abortion care, Maternal, Newborn and Child Health (2010). This document delineates essential care that mothers and babies should receive during the first six weeks after birth. In total, I interviewed thirty mothers, ten in each of three villages located near the capital of Kathmandu. My interviews asked women to describe the postnatal care they received from healthcare workers, as well their expectations and beliefs about postnatal care. My findings showed that most women who participated in the study did not receive WHO recommended services.
An Alarming Arrival and Culture Shock
Before writing my grant proposal, I, like most Americans, knew little more about Nepal than that it is home to Mount Everest and the Himalayan range. It may have been the jet lag after twenty-five hours of travel, but upon landing in Kathmandu, I was quite overwhelmed. Garbage lay burning along the roads, and stray cows, chickens, goats, and dogs roamed the streets. It took me several weeks to adapt to the spiciness of the food, as I was more accustomed to minimal seasoning and spice.
During my two-month stay, Little Angels College of Higher Studies was my home away from home. This private boarding school serves students from kindergarten through post-secondary levels. It is in Hattiban, near Kathmandu in the rugged Hills region, and just minutes from my research locations: the villages of Thaiba, Godawari, and Harisiddhi. I lived alongside Nepali nursing students in one of the school’s dormitories, and immersed myself in their culture.
On a typical day, I woke up at 7 a.m. to join the other nursing students for a traditional breakfast, which consisted of tea, eggs, fry bread, and a curried chickpea sauce for dipping. Next, my interpreter and I were driven to one of the villages to conduct interviews. I then returned to Little Angels to eat dal bhat, a curried rice and lentil soup. After a few hours of rest, which were typically spent reading outside or gazing at the Himalayan foothills, I reviewed my field notes and worked on analyzing the interview responses. Dinner was another serving of dal bhat with fresh vegetables, and I finished the day by socializing with the nursing students.
The author and her foreign mentor, Mrs. Purna Devi Shrestha, staff nurse and lecturer in nursing at Little Angels.
Most meals were uneventful, but one cultural mishap proved to be quite memorable. As a Hindu country, the Nepalese believe the left hand is unclean, and that only the right is to be used for eating. I am left handed, so I knew this aspect of Nepali culture would be difficult to adapt to. At dinner one day, my natural instincts took over, and I was eating with my left hand. I didn’t realize it at first, but everyone in the room (all of whom were Nepalese) gave me strange looks. Needless to say, I never made this mistake again, no matter how tired or distracted I may have been.
Despite my cultural idiosyncrasies, Little Angels accepted me as part of the family, and the support they provided was crucial to the success of my research. The administration team put together my daily schedule, organized my in-country travel, reserved cars, and aided me in all paperwork necessary to conduct research in Nepal. My foreign mentor, Mrs. Purna Devi Shrestha, a staff nurse and educator, provided invaluable help refining my research topic, creating a structured interview, completing an initial analysis, and scheduling my hospital visits. Little Angels also provided an interpreter, Dr. Yashaswi Rai, a physician interested in obstetrics and gynecology. In addition to being translator, interpreter, tour guide, and companion, she was an amazing source of information about local medical and cultural practices.
Learning from Others
My study of the quality of postnatal care received by women and their babies in the three rural villages developed from the previously cited WHO packages of services. These guidelines recommend essential services that all mothers and babies should receive after birth. This care includes an assessment of the mother’s bleeding, assessment of her breasts, temperature of mother and baby, weight of the infant, education regarding breast feeding, nutrition, tetanus toxoid vaccination, family planning, home care, danger signs, hygiene, cord care, warmth, and infant immunizations.
The ten women from each village who made up my study sample were between the ages of eighteen and thirty-five and had given birth within the past year. Through my translator, I first described the purpose of my research and confidentiality of the interviews, and then asked for formal consent. Amazingly, every mother I spoke with agreed to take part. Structured interviews were used. Guidelines of a structured interview state that questions should be asked in the same order and included in all interviews. Examples of questions are “Was a health care provider present for your delivery?”, “Did you seek postnatal care?”, and “What are your overall feelings on postnatal care?” I also inquired about traditional care, social and demographic information, personal experience, and expectations for care.
A volunteer at each village helped find new mothers to interview; however, Yashaswi and I were most successful by walking around the villages ourselves, looking for infant-size laundry and asking anyone we saw if they knew a new mother. More often than not, they knew of one and would walk us all the way to the mother’s home. On one occasion, our driver decided to help in our search for interviewees. He spotted a woman holding a baby and quickly turned our vehicle around and stopped alongside her. After a brief discussion with Yashaswi, this woman and her baby joined us inside the van where the interview was completed. As much as I enjoyed experiencing the home life of each woman I interviewed, I will never forget this one interview completed on the side of the road in a van.
One of the biggest surprises of my research was the hospitality of these women. Not only did they agree to take part in my research (which provided no form of compensation), but every mother invited me into her home. Many even asked me to stay for tea! This type of door-to-door hospitality would never be possible in a culture such as the U.S., and I am eternally grateful for the openness of these mothers.
Revealing the Truth
From the sample of thirty mothers who agreed to participate in my study, three of these women, one from each village, received two of the fifteen essential postnatal care services for themselves and their infants. In these three cases, the mother received the tetanus toxoid vaccine and her baby received appropriate immunizations, but no other care was reported. Not one mother reported receiving all fifteen essential services. Seven women reported receiving five care services, and the services they received varied from woman to woman. The highest quality of care was given to a mother and her infant in Harisiddhi, who received eleven of the fifteen essential care services.
It was important for me to not only analyze the data from my interviews, but also to learn about each woman and her life. The mother from Harisiddhi who received two essential care services was an eighteen-year-old housewife with a sixth grade education, and her baby was three months old. In addition to receiving almost no postnatal care for herself or her infant, she did not receive any care from a health professional during her prenatal months or delivery. Instead, she relied on family and friends for advice and care. This mother did receive the tetanus toxoid vaccine after the birth, although she stated, “I did not want the injection but I was forced to take it.” Since delivery, she has listened to her family’s advice and visited the nearby health post four times for her baby’s vaccinations.
In contrast, the mother who received the best care, also from Harisiddhi, was thirty-five years old with a third grade education, and had a nine-month-old as well as a thirteen-year-old. In terms of postnatal care, her bleeding and temperature were assessed, her baby was assessed for weight and temperature, and she received education on breastfeeding, nutrition, home care, hygiene, and warmth. Furthermore, her baby was up to date with all appropriate immunizations. However, her breasts were not assessed, and she did not receive education on family planning, danger signs, or cord care. During her prenatal period, she was diagnosed with gestational diabetes and spent the last month of her pregnancy in the hospital. Her health complication and prolonged hospital stay were most likely the reasons for her relatively thorough postnatal care.
View from the author's dormitory porch at Little Angels, overlooking rice patties, local homes, and the foothills.
An important finding uncovered from my interviews was that healthcare professionals could give inaccurate information to mothers or mothers would not understand the correct information presented to them. An example of misunderstanding was a mother who was told, “Keep the baby warm and keep him in warm clothing otherwise he will get pneumonia.” First, pneumonia is most often caused by infection and is not related to warm clothing. Secondly, while it is important to keep newborns warm, it is also important not to overheat them. On the day of our interview, the air temperature was 93°F. Her baby was swaddled in several fleece blankets and a thick wool hat, and was visibly sweating. With the help of my interpreter, I provided teaching about the dangers of infant overheating and how to dress an infant appropriately for the environment.
The mothers who generously participated in my study also provided eye-opening insights regarding their opinions and expectations of postnatal care. I found that many of these women had very low expectations, and they were happy to receive any care at all. One mother said, “I cannot say the care is [the] best in world, or [that it] is very good. I think it’s not that bad for a rural area like this, and for people like us. We cannot expect more so it’s fine.” Another mother said, “I was not told anything at the hospital. There it is always so crowded and they don’t have time to talk with everyone.”
During several observational visits to hospitals in the region, I was able to confirm that the maternity wards were very crowded. One of the resident physicians described them as “baby factories,” and that is exactly what they looked like: mothers were transferred from room to room depending on their progress in labor, and deliveries occurred side by side in one room. A hospital that I visited did not have enough beds in the postpartum ward, so women who had given birth only hours earlier were forced to spend the remainder of their hospital stay, which included personal care and sleeping, in the crowded hallway. Not only is this an unfit environment for rest, recuperation, and bonding of mother and baby, it also creates a high risk for contracting infections.
My deep interest in Nepal is rooted in its rich culture and geographical landscape; however, the extreme Himalayan terrain that I find so fascinating is a significant barrier to accessing essential healthcare. From discussions with several healthcare professionals, I learned of the long distances between villages and the widely scattered health posts. Connecting roads are narrow, winding, and often difficult to navigate by car. Villagers and healthcare professionals often ride horses or walk two to three days to reach the nearest health post. For many people, this extreme commute is too difficult and healthcare services are never utilized. In contrast, people in more metropolitan areas, such as the Kathmandu valley, have access to hospitals and health posts. Despite this convenience, they must have their own transportation, hire an expensive taxi, or take a crowded public bus on dangerous, bumpy, and crowded roadways. Additionally, monsoon season regularly brings landslides, floods, and road collapses throughout the country.
This photo, taken at one of the research villages, shows the isolation and rough terrain found in Nepal.
Despite the evidence of critical deficits in postnatal care, many mothers remain optimistic. A particularly insightful mother told me, “Before we die, we need to live and we need to take good care of our health. We need to stay strong and healthy, earn for a living, and give good education to our children. I want others to be healthy by taking the care they need in their postnatal periods.” When talking about the importance of postnatal care, another woman said, “This period is actually a very critical time because if you get good care, then not just the mother but both the mother and the baby can be very healthy.”
Although my research focused on postnatal care for women and infants in rural Nepal, the experiences of other women in the developing world may be similar. According to the WHO packages of interventions, quality postnatal care depends on both assessment and teaching provided by a trained health worker (2010). All women and newborns should be thoroughly assessed during the postnatal period. If any components of an assessment are overlooked, a serious complication could be left unaddressed. Additionally, teaching is an essential aspect of postnatal care, as it provides a mother with information on how to care for herself and her newborn. Not only should this teaching be accurate, but it must also be presented in a way that a mother can understand, remember, and apply. In a worst-case scenario, poor postnatal care has resulted in death for a mother or infant.
Future research is warranted on this subject, not only in Nepal, but also in other developing nations. I intend to present my findings to Little Angels Nursing Program, and to reiterate the importance of thorough assessments and appropriate teaching by nurses. It is my hope that by placing an emphasis on this issue in their curriculum, Nepal’s future nurses will be able to improve the quality of postnatal care for newborns and mothers for generations to come.
This adventure would not have been possible without Mr. Dana Hamel, Mr. Carlton Allen and the Class of 1952 for their generosity; Georgeann Murphy, Peter Akerman, Paul Tsang, and the entire Hamel Center staff for their support and encouragement; Dr. Gene Harkless, whose passion, knowledge, and mentorship inspired me to pursue this research experience; and Mrs. Purna Devi Shrestha, Dr. Yashaswi Rai, Professor Radha Ranabhat, Mr. Laxman Mandal, Ms. Shristi Limbu, Mr. Bhupendra Raut Ovc, and the rest of Little Angels administration, nursing staff, and nursing students for their incredible hospitality, warmth, and friendship. A final thank you to my friends and family for not thinking I was TOO crazy for embarking on this two-month journey alone, and for their continuous love and encouragement in everything I do.
UNICEF. Nepal Statistics (2011). Retrieved from http://www.unicef.org/infobycountry/nepal_nepal_statistics.html
World Health Organization. Postnatal Care (2010). Retrieved from http://www.who.int/maternal_child_adolescent/topics/newborn/postnatal_ca...
World Health Organization. Packages of Interventions for Family Planning, Safe Abortion Care, Maternal, Newborn and Child Health (2010).
Author and Mentor Bios
Stephanie Winn, a native of Pelham, New Hampshire, is a nursing major, graduating in May 2014. Through an International Research Opportunities Program (IROP) grant, she was able to explore postnatal care practices in rural Nepal. Interested in pursuing midwifery as a career, Stephanie found her adventure in Nepal to be both an invaluable exposure to the field of nursing and a chance to see the real-life applications of her studies. Both the research and cultural aspects of her nine-week journey—from conducting interviews to being welcomed into the homes of the mothers—provided good memories for her. Stephanie found out about Inquiry through the IROP office, and views the online journal as an opportunity to share her unforgettable experiences with others
Gene Harkless, DNSC, APRN, FAANP, is an associate professor and chair in the Department of Nursing. A family nurse practitioner who has taught at the University of New Hampshire since 1985, Dr. Harkless is a frequent mentor. "Helping curious students engage in projects that aim to improve health in some of the most underserved areas of the world has been a work of love for me. For the students, it is often life-changing as their world view is transformed. Through the research experience, a critical and empathic lens is honed as they confront questions and search for answers that may one day lead to large scale improvement. It is joyful and engaging work for both of us."
Dr. Harkless has mentored Inquiry authors Cristina Joseph (2006), Jennifer Herman (2007), Emily Roberts (2008), Lindsay Bergmann and Allison Reilly (2010), Lauren Kasparian and Rachel Butterfield (2011), and Sofia Cadime (2013).
Mrs. Purna Devi Shrestha is an assistant professor at the Janamaitri Foundation Institute of Health Sciences/Little Angels College of Higher Studies, Hattiban, Lalitpur, Nepal. She is a lecturer in the bachelor of science in nursing and the post-basic bachelor nursing programs and also is an advisor for research. Mrs. Shrestha was of invaluable help to Stephanie in carrying out her research in Nepal.
Copyright 2014, Stephanie Winn