Grant Report 2016 Q1: One Heart World-Wide

5/16/2016

January – April, 2016

District Health Office building in Bhojpur District, Nepal

Background

Bhojpur is a hill district located in the northeastern part of Nepal. It is home to 172,098 people, and reports 4,474 pregnancies per year. In 2014, One Heart World-Wide started the needs assessment process for this district, but due to the earthquakes that destroyed parts of Nepal in 2015, we had to pause our initial program activities and focus on districts such as Dhading and Sindhupalchok, where over 90% of the health facilities sustained either full or partial damage.

In late 2015, we started up our program activities in Bhojpur again, and in 2016, we have started rolling out the second phase of our Network of Safety – Program Implementation. Over the next three years, we will train community outreach providers, implement a community outreach program, upgrade health facilities into birthing centers, and train Skilled Birth Attendants. We will also develop a basic health infrastructure, provide health education, and foster community empowerment in collaboration with the local District Health Department. Our goal for the next five years is to double the rate of deliveries with a Skilled Birth Attendant, and reduce the maternal and neonatal mortality by at least 50%.

A sick baby at a Bhojpur district hospital with his mom.

Project Activities

Solar Suitcase Installation: Nepal heavily depends on hydropower, and rivers dry out during the winter. This results in huge electricity outages up to 18 hours a day during the winters and dry season of the year. For the birthing centers that are located in the more remote areas of Nepal, the sporadic electricity compromises the ability of the skilled birth attendants to provide safe delivery services during the nighttime, and increases the risk of complications during delivery. In order to fulfill the power needs of the rural birthing centers, we have currently installed 15 solar suitcases in birthing centers around Bhojpur. These suitcases not only provide essential lighting for the delivery and waiting rooms, they also contain a fetal Doppler, mobile chargers and two sets of rechargeable headlamps.

Solar Suitcase Team training staff members at Mane Bhanjyang Birthing Center in Bhojpur.

Needs assessment to expand new birthing centers: Many women don’t receive emergency care immediately as needed because of three delays:

Delay in deciding to seek care
Delay in reaching care
Delay in receiving adequate care

The ability to reach a birthing center in a timely manner is a major delaying factor because of the geographic barriers resulting from the mountainous and hilly regions of Bhojpur. Birthing centers are far and wide, and as there are not many roads in the Bhojpur district, reaching a birthing center often requires several hours of walking. Our aim is to increase the number of birthing centers in strategically located existing health posts. We will work in collaboration with the local community to renovate and upgrade existing birthing centers for women seeking emergency obstetrics as well as antenatal and postnatal healthcare services. With the help of the district health offices, we plan to identify 8 to 10 new sites to provide delivery services in the next three years.

Construction of the new Tiwari Bhanjyang Birthing Center in Bhojpur.

Quality of Care (QoC) Assessment of Birthing Centers: The quality of care received by mothers and babies in remote areas is often reported as poor. Poor sanitation and bad hygienic practices can lead the infection to the mother and newborns. Infection is one of the major causes of maternal and newborn death globally and locally. Quality care assessment is one of the routine activities completed so that all women and newborns can receive clean and dignified care during the delivery.

SBA Training: Pregnancy is a natural process for which medical assistance is not considered as a need or requirement in Nepal. As a result, many Nepalese women, especially those residing in more rural areas of Nepal, deliver at home. In most communities, traditional birth attendants are usually primary service providers who have never received modern training in midwifery. The lack of training poses a risk to the lives of the women and newborn. Currently, there are only a few SBAs that serve about 45,000 women per year in Bhojpur. One Heart World-Wide has identified several eligible nurses that are on their way to becoming certified skilled birth attendants. Post-training, they will be able to provide the maternity care necessary to conduct safe deliveries in this district.

Auxiliary Nurse Midwife trained in Skilled Birth Attendance holding a newborn in front of a solar suitcase at Tiwari Bhanjyang.

2015

In early 2015, we started discussion with the District Health Office (DHO) of Bhojpur and drafted a Memorandum of Understanding (MOU) between One Heart World-Wide and the DHO.
We were able to sign all the necessary MOUs and agreements to start work in Bhojpur. However, the earthquakes delayed the start of our regular programs in Bhojpur, which included the baseline data collection process, hiring a field team, and setting up the field office.
We re-started the activities listed above again in Quarter 4 of 2015, and successfully hired staff and set up the field office in Bhojpur. One Heart World-Wide also conducted a Rapid Assessment and started a comprehensive data collection process before creating a program roll-out plan to share with the DHO.

2016

In 2016, OHW committed to partially supporting the construction of the Birthing Center at the Tiwaribhanjyang Health Facility in addition to providing essential delivery equipment and Solar Suitcases.
On February 1st, OHW Network of Safety program was formally launched.
We have enrolled nine Auxilliary Nurse Midwives into a two-month training program for skilled birth attendants at the Sagarmatha Zonal Hospital.
We have installed Solar Suitcases in a total of 15 health posts in Bhojpur.
We have conducted Quality of Care assessments and needs assessments for 11 birthing centers, along with plans for future improvement and partnership with the HFOMCs at these existing facilities. These include: Charambi Health Post, Pyauli Health Post, Basteem Health Post, Annapurna Health Post, and Chinnamakhu Health Post, Ghoretar PHC, Patlepani BC, Helaucha BC, Bhojpur District Hospital, Pawala BC, and Pangcha BC.
6 Birthing Centers Joint Monitoring visit - The purpose of these visits was to determine the overall status of each birthing center, and also monitor maternal and neonatal mortality. The District Health Officer of Bhojpur, Dr. Nawal Kishor Jha, joined the OHW team to supervise the visits. These Health Facilities include: Ranibas PHC, Patlepani HP, Basteem HP, Tiwaribhanjyang HP, and Pyauli HP, Ghoretar PHC.
25 District Supervisors Trained with a 3-day training on Health Facility Operation and Management Committee (HFOMC) District Train-the-Trainer training.
Annual targets and deliverables are set for 2016.

Data

Upcoming Plans

We are planning to continue with the Quality of Care assessments, along with a needs assessment and plans for future improvement at additional birthing centers that have been identified.
Two FM stations will be mobilized for Radio Airing. A safe motherhood and neonatal health related jingle will be aired.
District level HFOMC Train the Trainer on HFOMC strengthening for District Supervisors.
We will be focusing on Community Mobilization on Under Performing VDCs.
We will also be training HFOMC members from underperforming health facilities on their roles/responsibilities, how to identify service delivery problems, micro-planning and to seek resources from VDC/DDC and DHOs.
We will also focus on renovation and infrastructure support to Birthing Centers.

Challenges

So far, we have been lucky enough not to have faced any major challenges since re-starting our program activities in Bhojpur.

Results

2016 Quarterly Goals

Case Story: Tulasha Khanal, Auxiliary Nurse Midwife

Story transcribed by: Suraj Shah, OHW
Photos by: Suraj Shah, OHW
Edited by: Alisha Giri
Location: Dhading, Nepal

Auxiliary Nurse Midwives (ANMs) displaying the solar suitcase equipment that was installed in their local Birthing Center.

One Heart World-Wide came into this rural area, installed a solar suitcase and also gave us training. This is something very big hearted from One Heart. Thank you many times to We Care Solar and One Heart World-Wide for such a novel work to save pregnant women and newborn babies' lives. Blessings from a mother’s heart and soul that will always follow you and brighten your path.

Namaste! (Hello!) My name is Tulasha Khanal. I am 35 years old and have been working as an Auxiliary Nurse Midwife since 1999. I am currently working here at the local Birthing Center. I am living with my in-laws, husband, and my only son, who is currently in school. My husband also works as a senior assistant health worker.
I always wanted to work in this field growing up, and it has become my passion. I have the full support of my family as well as my husband.

Three years ago I received Skilled Birth Attendant (SBA) training and since then, I’ve been working as an SBA/Auxillary Nurse Midwife. Currently, we are facing the problem of lighting for deliveries that take place at night. Currently 90% of the deliveries we do at this center are at night. We don’t have a reliable option for a steady power source and sometimes have to resort to using a simple hand torch or even our mobile phones for night deliveries. We also have 13-19 hours of load-shedding every day in this area. (Load-shedding is the deliberate shutting down of power by the government to bypass shortage of electricity).

For surgical procedures such as an episiotomy, I will sometimes have to ask individuals accompanying the patient to hold the torch for me while I perform the surgery. While we are used to these procedures, it can be frightening and nerve-racking for these individuals and the patients themselves. They tend to get nervous and start shaking so that the light source they are holding is not steady, which forces me to perform partially in the dark. This exponentially increases the already high risk of complications, especially during serious procedures. The responsibility of saving the mother and newborn baby’s lives in these conditions is a heavy responsibility and poses a serious issue that we face in these rural birthing centers.

Just this past month we had a case with a pregnant woman named Gauri Lama. She came in during the day and I used my judgment and past experiences to conclude that she would deliver her baby before 6PM. Six PM came and went and she was still there, unable to push, with no sign of delivery. By 9PM she was still here and still no signs of delivery, although there had already been a Meconium stain. I started to do all the procedures that I’d learned through my training and realized that the baby had already inhaled the Meconium. I had asked one of the sisters to help hold a light for me, and by this time, the torchlight was already at low power. With a lot of difficulty, I started the emergency procedure, and with much difficulty, I was able to successfully take the baby out and immediately start resuscitation. During this, the torchlight died and we were forced to start using our mobile phones for lighting. This is just an example of one of the many cases that I’ve had to perform with very limited lighting.

Tonight also I have pregnant women who are ready to delivery, but I'm very happy and much more confident because now we have new solar power inside our delivery room. This light was really very important for us. Now I can do my job in the best way without proper lighting.

Today I feel like a kid at a candy store. Having these solar lights will make our work so much easier and save more lives. The two beautiful bright lights will not only brighten this one room but because of the long cord, we can use them to light rooms and passages, and charge devices such as the Fetal Doppler. In an emergency, it’s difficult to put a Fetoscope in to listen for the baby’s heartbeat. Now, we will be able to allow the pregnant mother and her family members to listen to the fetal heartbeat and I can instruct my assistant to listen as well. We also got two new headlamps so now I don’t have to rely on untrained individuals to hold up a light. I can focus a steady light on exactly what I need to successfully complete any procedure. The multi-mobile charger we received also makes a huge difference when working at night, as I often tend to run out of charge on my phone since I use it to make frequent calls to prepare ambulances, inform my colleagues, or request help. I’ve had situations where my phone dies right in the middle of a conversation like the ones mentioned above, and there is no power to charge it back. Even just a few minutes of delays due to lack of power can have a huge impact.