Namaste from Nepal!
The remote areas research project is proceeding well; I just returned from a field trip where we launched the study. Since I unfortunately cannot speak Nepali, I can’t actually participate in data collection itself. But I participated in the development of the survey tools, so I offered my help to field staff by providing oversight and organization.
Nepal is divided into three radically different ecological zones: the flat, hot terai in the south; a band of hills that cuts across the middle of the country (home to the capital, Kathmandu); and the mountainous north straddling a lengthy border with China. My field trip was to one of these northern mountainous districts. (To protect confidentiality, I will not identify which district I visited, and will instead refer to it as “District A” throughout this post.) Per the 2011 national census, the headquarters of District A (where we stayed, and home of the district’s only hospital) has fewer than 3000 residents. Much of the district is covered in protected conservation land, and it is a common destination for trekking tourists. It is sparsely populated and breathtakingly beautiful.
There is a single paved road in the district, and it weaves dramatically from one mountaintop to another. Transport otherwise is quite difficult: unpaved roads have dramatic inclines and curvature, and many are washed out during annual monsoons so constantly must be recreated, with old sections abandoned as perilous drop-offs. The mountain fronts are also covered in many small rivers, cascading quickly now as warming seasonal temperatures melt the snow above. Although this all produces a beautiful natural environment, it also poses significant geographic challenges in moving around the district.
As I mentioned, there is only one hospital in this district; it offers basic emergency obstetric care, and no neonatal emergency services. From some parts of District A, the hospital is reached only via a multi-day walk. So outside the district headquarters, women who want medical care at birth visit their nearest birthing center at a health post—which also may require a long journey, and only offer assistance for normal deliveries.
To an observer such as myself, there are seemingly many barriers to utilizing services for maternal, neonatal and child health in places like District A. From geography to service availability, the path to receiving care seems fraught with challenges. But health workers in remote areas are deeply engaged in their communities, familiar with every household. They know all women who are currently pregnant, and can target them through direct household visits, through their social networks, and through community health volunteers.
So for all the barriers to care, there are also enablers. How these shake out in terms of perceived access to care (among women), and perceived challenges to delivering care (among providers)—that’s what this remote areas study aims to uncover. Stay tuned for results!
10 May 2013
Happy mother’s day! What a fitting time to reflect upon childbirth – the wondrous process of bearing new life, but also the immense risks this poses for too many women around the world. As we well know, these dangers vary greatly across populations, revealing a substantial global inequity between the rich and the poor.
I am working on maternal health research in Nepal, where mother’s day was in fact celebrated earlier this week. Nepali women long faced a very high risk of dying during childbirth. But this has decreased over the past decade, owing in no small part to concerted efforts by the government and development partners including donors and NGOs. Nepal is in fact on track to meet its maternal health MDG, which is an enormous and commendable accomplishment. But recent estimates of maternal mortality are still too high, suggesting that progress remains to be made; and large disparities persist, particularly related to socioeconomic factors and to geographic location.
During my time here I am assisting with, and learning immensely from, a project by the Ministry of Health and Population on maternal and child health service utilization in remote areas. These remote areas are typically understudied and there is much that is not understood about barriers to seeking and accessing care. This research has two aspects: a team of Nepali medical anthropologists and sociologists have developed a qualitative study to understand demand-side barriers to health service utilization for women and children; and a team of health economists and clinicians have developed a mixed methods (qualitative and quantitative) study that will investigate supply-side barriers to service delivery. Together, the findings will serve to inform the Ministry and its partners on how to increase utilization and improve health outcomes for women and children in these remote areas. The project is now in the final stages of planning, and we hope to head to the field next week.
My role with the project so far is to provide general research support, particularly to the supply-side team given my specialization in health systems. I am helping to finalize the data collection tools, engaging in discussions about study design, and I participated in training of the data collection teams. Additionally, I am using my knowledge of GIS to create maps for the project, representing population distribution, geologic features, and locations of different types of health facilities plus which services they offer. These maps are important because basic distance measures may not be a very informative metric of health system access – particularly in Nepal, which is home to eight of the ten highest peaks in the world. In the study areas, some villages can only be reached via a weeklong walking journey from district headquarters, which is usually the location of the only obstetric care facility in that district. So if a woman in one of these remote villages experiences a serious complication during childbirth, she has almost no chance of accessing emergency obstetric services. The research team will thus use these maps during qualitative data collection, to learn more about how women decide where to seek health care, and how metric distances translate into travel time and expense.
I am eagerly anticipating field work, to gain a better understanding of the barriers faced by women as they make decisions about where and when to access care. This type of knowledge is crucial in developing effective and equitable policies to save mother’s lives, the topic to which I have dedicated my own dissertation research. I feel so lucky to have been given this incredible opportunity to engage with such important issues in a first-hand and in-depth way. Will write more soon, hopefully from the field!