Observing Plan International’s Work to Improve Maternal Health in Rural Nepal
I’ve been a Digital Ambassador for the global children’s charity Plan UK (the UK arm of Plan International) for over a year now and I’ve loved supporting the charity’s campaigns, fundraising, learning more about their work and sponsoring a young girl in Honduras through the charity. As well as writing about their campaigns and raising awareness about the causes they tackle, such as child abuse, violence in schools, child marriage and FGM, I’m now fortunate enough to have seen their work in action on the ground in Nepal, meeting the key people who make it happen, and talking to the local communities who benefit from Plan’s projects.
Visiting a Plan International project
As you know, I’ve spent most of 2016 so far in Nepal, in the region of Makwanpur. Fortunately for me, one of Plan International’s key offices in Nepal is located in the town of Hetauda, not far from where I was living. I had the opportunity to meet the staff, including the Health Manager Mihir Kumar Jha and the Programme Unit Manager Netra Prasad Upadhyaya, and to even spend a day observing the training of a maternal health project in the VDC of Sripur Chhatiwan. Seeing it come to life in Nepal first-hand, rather than just reading a report back here in the UK, was fascinating and it’s made my understanding of the charity 10x richer.
Plan International’s background in Nepal
Plan International first established a presence in Nepal in 1978, setting up projects in Makwanpur since 1995, so they have a long history in the area. They’ve run hundreds of projects so are well-recognised in the local villages and as the staff are all local, they’re the experts on what problems need addressing and how best to do that. Their focus is predominantly on children but their thematic areas cover health, education (eg. funding the high school near my village), water sanitation and hygiene (eg. installing the first water systems and taps 20 years ago), livelihoods, child protection and rights (eg. fighting child labour and domestic violence) and disaster risk management (eg. earthquake relief).
Tackling maternal mortality in Nepal
The particular project I visited focused on maternal health during pregnancy, ensuring the mother is safe and the baby is born as healthy as possible. In 2001 in Makwanpur district, with a population of 420,000, there were 480 maternal deaths in a single year, and through the hard work of NGOs such as Plan, a decade later this nearly halved to 281 maternal deaths. While a big improvement, that’s still frighteningly high for something that has been virtually eradicated here in the UK. According to data from the World Bank, Nepal’s maternal mortality rate in 1990 was 90 times higher than in the UK. However, things are gradually improving, as in 2015 Nepal’s maternal mortality rate had dropped to 29 times that in the UK.
What my day with Plan Nepal taught me is to think beyond the statistics. Obviously we want statistics to improve, and we want to hear that the money we’ve donated has produced results. But how do you actually go about improving maternal mortality? That’s what the people on the ground have the challenge of actually doing and it’s something I had only given a summary thought to, before meeting them in person and discussing the issues they face in implementing development projects.
Pregnant Women’s Groups
One very successful technique to improve maternal mortality that Plan created in 2006, which they are now rolling out across Nepal and hopefully to other Plan International countries worldwide, is Pregnant Women’s Groups (PWGs). These groups are run by government-appointed Female Community Health Volunteers – local women who live in villages across Nepal and who are given basic training and access to health resources. The reason these local Health Volunteers are so crucial is that Nepal’s population is so geographically spread out, and its infrastructure and roads so poor, that quite often an ill person would need to walk several days just to reach the nearest Health Post. Even for those connected by road access, the cost of transport is often prohibitively high and they’re not accustomed to leave their village often. As an example, my host mother in Bhalu Khola, despite living just 30 minutes by bus from the nearest town Hetauda, only travels there once or perhaps twice a year at best. The rest of the year she stays in her village and only travels as far as her feet will carry her.
These Health Volunteers are the main link between the health authorities and the pregnant women in Nepal. What Plan International are doing with this PWG initiative is training these Female Community Health Volunteers in a technique that educates soon-to-be-mothers on the precautions and check-ups to do during their pregnancy, and it’s been designed as an accessible peer-supported technique that takes into account varying levels of literacy and education. In 2011 a huge 40% of women aged 15-49 in Nepal were illiterate, having received no education whatsoever. So the Health Volunteers are trained and equipped with materials (both in Nepali and depicted visually for illiterate women) to help raise awareness of the 10 key steps that all pregnant women must take. These include steps like check-ups, iron tablets, tetanus & diphtheria vaccinations (all of which are provided free by Nepal’s Health System) but also extend to post-birth, ensuring that the baby’s birth is registered with the government within 35 days. They encourage pregnant women to follow these steps through two approaches:
- Financial incentives: If the baby is registered within 35 days of birth then mothers receive 400 rupees, and they can also receive up to 1,000 rupees for transport costs to a Health Post for check-ups and the actual delivery of the baby.
- Healthy peer pressure: Through social mapping, the Health Volunteer draws a large map of the village and at each Pregnant Women’s Group meeting, she indicates the houses of the pregnant women by sticking a paper house onto the corresponding parts of the map. The 10 different steps of the pregnancy that the women should follow are then indicated by 10 different coloured tikkas (aka bindis – the red dot that many Hindu women wear between their eyebrows) that are stuck onto their particular house as they complete each step. The idea of representing their pregnancy’s progress visually on a large public map is so that other women in the in the group can see what stage they’re each at, can offer support to one another, and motivate one another to all stay on track together with the various steps. When the woman’s house on the social map has all 23 required tikkas, then she can exit the programme and receive her compensation from the government.
The importance of education, awareness and dispelling myths about pregnancy and childbirth
Not only do the PWGs ensure all pregnant women are aware of the services available to them, and the steps they should take, but it’s also an excellent opportunity to educate the rural women about some of the stranger and unhealthy traditions that are sometimes followed. I had a chance to observe a full day’s training of 16 Health Volunteers, to watch them run a real Pregnant Women’s Group with 4 pregnant women in a ward of Chhatiwan, and to interview a few of them (through a very helpful interpreter) about their lives and personal experiences of childbirth. What the Health Volunteers told me astounded me. Here are just a few of the old traditions they told me about:
- Pregnant women continue working in the fields, carrying their heavy loads of 40-60kg strapped to their foreheads and looking after their households, right up until the labour pains begin! It’s believed that the delivery will be easier if the woman keeps working.
- After childbirth, the woman is considered unclean and not allowed to enter the kitchen for up to 22 days.
- Cow dung (considered sacred in Nepal and used everywhere, on indoor walls, on indoor floors, etc.), soil, mustard oil, turmeric powder/oil and ashes are applied to the umbilical cord after cutting (a practice which often leads to tetanus).
- The umbilical cord is sometimes cut with a sickle (often causing tetanus).
- Tomatoes are applied to of cuts and wounds to heal them. In my village I even saw salt erroneously being rubbed into wounds to help healing.
The 16 Health Volunteers that I met and interviewed that day were all wonderful, selfless women who dedicate so much of their time to their communities, in return for inadequate compensation from the government for their services. They each have a great responsibility for the health of their community and they need all the help and resources they can get, and Nepal’s Health Service relies heavily on organisations like Plan International to set up initiatives such as these Pregnant Women’s Groups, to provide the necessary training and materials. Plan Nepal’s Health Manager in Makwanpur, Mihir Kumar Jha, planned and delivered the two-day training (of which I joined the second day) in Chhatiwan, and it’s through Mihir’s tireless work across the region that this new technique is spreading through Makwanpur District. I’m so grateful to Mihir for allowing me to join them and to learn about Plan Nepal’s work in this area.
Learnings from my day observing a Plan International project in action
My biggest learning from observing a Plan International project on the ground was just how much time and effort, dedication and perseverance is required to make positive change a reality. Plan’s staff face innumerable challenges in their work and there are so many external factors at play which they must navigate in order to get a project off the ground and working to improve the current situation. Development is a slow process in a poor nation like Nepal, with hurdles at every single corner: from lack of funding, to governmental bureaucracy, to difficulty securing resources, to poor infrastructure, to lack of education and myriad other factors. Having seen it in action with my own two eyes, I have to say that in all honesty, running a marathon and fundraising sound like a piece of cake compared to the legwork that actually takes place on the ground! I do now firmly believe however that thank goodness there are international organisations and good people out there who do struggle against all odds to make these projects a reality, as Nepal is truly in dire need of more support of this kind, if any change for the better is to be seen in Nepal!
During my 3.5 months in Nepal, I came to love the country and the Nepali people, many of whom I consider best friends and family members, and I desperately want to see their situation and their lives improve. They do not deserve the poverty and social issues they are born into and have to suffer all their lives.
If the day I spent with Plan International in Nepal taught me anything, it’s that we must continue working, striving and struggling to get these projects implemented more widely. I couldn’t be prouder to be an ambassador for Plan International, an organisation that truly does have a big impact on the communities where it works, in countries such as Nepal where it’s been working for nearly 40 years already!
Thank you so much to everyone at Plan Nepal in Hetauda and to the Plan UK team here in London, for arranging my visit to spend a day with the Pregnant Women’s Group in Chhatiwan. I’m deeply grateful and touched to have been allowed access to such an inspiring project and I wish everyone involved in the PWG project all the luck for the future – keep on working to make the world a better place and you are all truly wonderful, caring people. You truly are an inspiration to me…