Life support

PUBLISHED : Sunday, 09 August, 2009, 12:00am
UPDATED : Sunday, 09 August, 2009, 12:00am

Asha screams with pain and exhaustion. Her body contorts in agony as she writhes on the hard wooden bed with its thin mattress; her knuckles bleeding and bruised from flailing against the bare stone walls of the cramped, dusty hut. The slight young woman has been in labour for more than 36 hours as her baby fights to enter the world.

Throughout the long and agonising birth, Asha's sisters take turns to comfort her but they are unable to help. None of them have ever attended a hospital or clinic appointment or seen a doctor or midwife.

The family lives in a village in rural Nepal from where the nearest clinic is a day's walk through jungle and over mountains. Not that any of them have the money to pay for health care even if they could reach a doctor.

In Nepal, one in 31 women will die from problems associated with pregnancy or childbirth complications, according to Unicef (the United Nations Children's Fund). In Britain, the figure is one in 8,200; in France it's one in 6,900.

Fewer than half of the country's 28 million people have access to roads and most mothers and newborns cannot easily access clinics or hospitals.

Most of the fatalities occur as a result of severe bleeding, sepsis, toxemia and obstructed labour.

Douglas Maclagan, founder of a charity called the Child Welfare Scheme (CWS), which was set up to help rural Nepalis and is largely funded by Hongkongers, says: 'We call it the three delays: the first delay is for mothers to recognise that something is wrong and make the decision to seek help; the second is trying to get to help (if they live in the mountains, for example, it could be a walk of several days before they can get to any facilities); thirdly, when they actually reach the health facilities, they often can't get the help they need because it's simply not there - there's no doctor, no medicine and no equipment for a procedure such as an emergency Caesarian.'

The World Health Organisation points out that skilled care around the time of birth would greatly reduce the number of these needless deaths.

Asha - which means 'hope' and is a popular name in Nepal - was dangerously close to becoming another tragic statistic until the intervention of a woman from a nearby village. She was one of a handful of locals trained as a community medical auxiliary by CWS and she undoubtedly saved the young mother's life and that of her baby's.

'I will always be grateful to her,' says a smiling Asha as she cradles her healthy little girl.

Ram Maya Tamang is a villager who has volunteered to undertake the CWS training programme. The serene young woman stands outside her humble house and says: 'I am glad to be able to help my community. It is very rewarding work.'

CWS was set up after Maclagan took a backpacking trip through Nepal in the early 1990s. The former teacher was approached by a young woman who thrust her dying baby into his arms and begged him for help. Sadly, it was too late for her child but it was an encounter that was to change the course of his life and save countless others.

'I wasn't a doctor or a magician but I knew I had to do something,' he says.

With no experience or money, he gave up his teaching job in Britain and set about building a network of educational centres and health clinics in a rural hill area of Nepal - the Kaski and Lamjung districts in the west of the country.

In 1996, he travelled to Hong Kong to raise funds and, until 2002, the majority of CWS' money - about 85 per cent - came from Hong Kong. It's now about 50-50 between here and the British arm of the charity. Last year, 91.5 per cent of the money donated went directly to projects on the ground with only 8.5 per cent being spent on administration, fund-raising and public relations.

In April this year, the CWS completed construction of its 14th and final day care centres.

Nepal is popular with tourists attracted by the the stunning Himalayas and ancient culture; it's the birthplace of Lord Buddha and is renowned for its magnificent temples. It's also one of the poorest countries in Asia and has suffered from decades of political instability.

Maoist rebels fought a bloody, 10-year civil war against government troops which killed thousands, before becoming part of the politi- cal mainstream in 2006 and joining a peace process. Their party then won the most votes in last year's general elections which helped topple the monarchy.

There was huge optimism, especially in rural communities, many of which still think of the Maoists as revolutionary heroes. But the country continues to suffer political turmoil.

In May, the prime minister resigned following a dispute with the country's president and the Maoists have branded the formation of the new government 'a farce'.

The country is also crippled by a lack of basic infrastructure. Towns and cities have to make do with just four hours of electricity a day while inflation is increasing the price of basic goods.

Nepal's per capita income averages US$340 compared with US$42,000 in Hong Kong. The United Nations estimates that about 40 per cent of Nepalis live in poverty and 85 per cent of the population lives in rural areas.

As the men increasingly migrate to urban areas in search of employment, the women have become the backbone of rural life.

Such women include Khumaya Gurung, who is an Early Childhood Development facili- tator (essentially a nursery school teacher) at the first CWS day care and health centre in the village of Saimarang. She wakes most days at 5am to prepare breakfast for her family and for some of the village men who are building the area's first road.

'They are working hard so that we can travel to the other villages and towns and we can bring food and clothing here more easily. This will be much better for our lives,' says Gurung.

Nepal's staple diet is a simple dish of rice and spiced lentils called dal bhat. Cooking is a lengthy and laborious process involving a ground-level stove made from cheap local materials (which is an improvement on the open fires they used before the Improved Cooking Stove programme was implemented 10 years ago).

To make chapatis, village women process their own flour using a backbreaking grinding tool that owes nothing to modern technology. Coffee is locally-grown and the milk comes from the buffalo that live cheek-by-jowl with the human population. It's sometimes sweetened with honey from beehives kept on the roofs of many village houses.

It sounds like a rural idyll and indeed it is possible to grow a myriad of produce in Nepal but the lush mountain terrain is also extremely rocky so there is a shortage of arable land, of which only about 20 per cent can be cultivated and that is often swept away by monsoons.

Saimarang day care and health centre was built almost 15 years ago by villagers who carried the materials from Pokhara - the nearest city, a day's journey through the mountains. Cement, heavy iron rods, nails, metal sheeting, plywood and much more were transported mostly on villagers' backs.

'It took 10 months to build altogether,' says Dasu Adhikari, who was construction supervisor and manager and is now head of human resources at CWS Nepal, CWS' main local partner.

'It was exhausting work and took much organising of materials, skilled labourers from Pokhara as well as voluntary labour from the villagers who were busy working long hours in the rice fields. Work was also delayed by the monsoon season.

'But the villagers were so excited to get such a facility that they were eager to do whatever was needed. There was no school for young children or medical post there before. They had to go to Pokhara when they were sick or injured.'

The centre is high up in mountainous western Nepal and provides post-natal schooling and basic health care to five surrounding villages.

Life in Nepal is tough - and short if you cannot access adequate health care. Many of the villages have no roads or electricity; squat toilets are flushed with buckets of rainwater. Drinking and bathing water comes from a communal tap in the village and is not treated. Dysentery is rife.

If someone falls seriously ill they have to be carried on a doko (basket) on the back of a relative or friend for days before they reach a clinic or hospital. For women experiencing a complicated labour, that may not be possible.

Andrew Clarke is a British health adviser who is responsible for developing basic services in Nepal's isolated villages and shanty towns, including providing a safe maternal care programme to reduce the death rates in pregnancy and childbirth.

'If they survive childbirth, many mothers are left with long-lasting difficulties. We aim to help reduce the risks associated with pregnancy, childbirth and early care, for both mother and baby. We also try to increase women's choices about pregnancy by providing them with information and access to family planning through the day clinics, mobile clinics and village health programmes,' says Clarke. 'The terrain and challenges in Nepal are so varied that one model or way of working cannot succeed or be relevant across the whole country.

'So we support the development of several approaches addressing similar problems.

'In the mountainous east of Nepal we are supporting a pilot project across an entire district called Solukhumbu [home to Everest]. This covers the whole population of 120,000 and about 5,000 women and babies each year. It's a collaboration between ourselves, a local non-governmental organisation and the government health service. Essentially in this case we are guiding existing Nepali government health services to work differently and, hopefully, more effectively.

'This is a challenging project but it is going well and some of the systems developed, while basic in some respects, are actually quite radical and happening for the first time in the country.'

Clarke says that in the south of the country, CWS supports another Nepalese NGO, which also works to improve conditions for pregnant women and newborns but in a different way.

In Nepal, women's groups are an integral feature of most communities. So, this initiative works through these groups and harnesses the influence and power they have within their communities.

'We achieve results by using them [the women] as vehicles for raising knowledge, awareness and demand for using services within their communities,' says Clarke.

The UN says that women's role in fighting poverty is crucial: 'We know that achieving gender equality and empowering women is not only a goal in itself, it is also a condition for building healthier, better-educated, more peaceful and more prosperous societies.'