Perceptions of service providers, service recipients and female community health volunteers on a rural obstetric ultrasound program in rural Nepal: a qualitative study.

BACKGROUND: In rural Nepal, where women face financial and geographic barriers in accessing ultrasound scans, the government initiated a Rural Obstetric Ultrasound Program (ROUSG) to train skilled birth attendants (SBAs) in rural birthing centers and expand access to routine ultrasound scans for local pregnant women. This study explores the perceived benefits and limitations of the training and implementation of this program. METHODS: A qualitative study was conducted in 15 primary care facilities in Bhojpur and Dhading, two rural districts of Nepal. The research team conducted in-depth interviews with 15 trained SBAs and focus group discussions with 48 service recipients and 30 FCHVs to gain insight into their perceptions. All interviews and focus group discussions were recorded, reviewed, and manually coded into MS Excel. RESULTS: Overall, our findings indicated that the ROUSG program was very well received among all our study participants, though critical gaps were identified, mostly during the training of the SBAs. These included insufficient guidance or practice opportunities during training and the challenges of implementing the mobile obstetric ultrasound service. Most importantly, though, our results suggest that the implementation of the ROUSG program increased access to prenatal care, earlier identification and referrals for abnormal scans, as well as reduced pregnancy-related stress. There was also a notable anecdotal increase in antenatal care utilization and institutional deliveries, as well as high satisfaction in both service providers and recipients. CONCLUSION: Our findings highlighted that while the training component could use some strengthening with increased opportunities for supervised practice sessions and periodic refresher training after the initial 21-days, the program itself had the potential to fill crucial gaps in maternal and newborn care in rural Nepal, by expanding access not only to ROUSG services but also to other MNH services such as ANC and institutional deliveries. Our findings also support the use of ultrasound in areas with limited resources as a solution to identify potential complications at earlier stages of pregnancy and improve timely referrals, indicating the potential for reducing maternal and neonatal morbidities. This initial study supports further research into the role ROUSG can play in expanding critical MNH services in underserved areas and improving broader health outcomes through earlier identification of potential obstetric complications.

Socio-culturally adapted educational videos increase maternal and newborn health knowledge in pregnant women and female community health volunteers in Nepal's Khotang district.

OBJECTIVES: While Nepal has made significant improvements in maternal and newborn health overall, the lack of maternal and newborn health-related knowledge in the more rural parts of the country has led to significant disparities in terms of both maternal and newborn health service utilization and maternal and newborn health outcomes. This study aimed to assess whether viewing culturally adapted maternal and newborn health educational films had a positive impact on (1) the maternal and newborn health knowledge levels among pregnant women and (2) the postpartum hemorrhage-related knowledge levels among Female Community Health Volunteers in rural Nepal. METHODS: Four locations were selected for their remoteness and comparatively high number of pregnancies. A convenience sample of 101 pregnant women and 39 Female Community Health Volunteers were enrolled in the study. A pre- and post-test design was employed to assess this intervention. Paired t-tests were used to analyze the change in number of correct responses by knowledge domain for multi-film participants, producing a numeric "mean knowledge score," and McNemar's tests were used to calculate the change and significance among select questions grouped into distinct themes, domains, and points of "maternal and newborn health-related knowledge" based on the priorities outlined in Nepal's maternal and newborn health 2030 goals. RESULTS: There was a significant improvement in knowledge scores on maternal and newborn health issues after watching the educational films for both types of participants. The mean knowledge score for pregnant women improved from 10 to 15 (P < 0.001) for the Understanding Antenatal Care (ANC) film, 3 to 10 (P < 0.001) for the Warning Sign in Pregnancy film, and 6 to 14 (P < 0.001) for the Newborn Care film. For the Female Community Health Volunteers, knowledge also significantly improved (P < 0.05) in all except one category after watching the postpartum hemorrhage film. The percent that correctly answered when to administer misoprostol (80%-95%) was the only variable in which knowledge improvement was not significant (P < 0.057). CONCLUSION: Using culturally adapted educational films is an effective intervention to improve short-term maternal and newborn health-related knowledge among rural populations with low educational levels. The authors recommend additional larger-scale trials of this type of intervention in Nepal and other low- and middle-income countries to determine the impact on long-term maternal and newborn health knowledge and behaviors among rural populations.

The Logarithmic Spiral of Networks of Care for Expectant Families in Rural Nepal: A Descriptive Case Study.

This case study utilizes the four domains of effective Networks of Care (NOC) as a lens to describe the suite of interventions of a biosocial approach to maternal and neonatal health services in rural Nepal: The Network of Safety model, created by the non-governmental organization One Heart Worldwide (OHW) in collaboration with the government health system in Nepal. This approach provides essential guidance in the areas of health financing, governance, sustainability, reflection of user preference, and scalability. OHW addresses the reproductive health needs of women living in remote areas of Nepal in collaboration with local-level health and government workers by emphasizing clinical skill development and mentorship in management and leadership. With Nepal's shift to Federalism, the OHW approach proved flexible and able to deepen its support to leaders in new local-level government structures. The results on the ground were remarkable: using analytic skills gained from their OHW partnership, municipality leaders and health workers demonstrated effective communication and proactive responses to challenges, while maintaining fidelity to the Network of Safety model. The six-year commitment made by OHW to partner municipalities promoted active learning and adaptation and is a clear contributor to the scalability of the OHW Network of Safety. Observing the Network of Safety work through the domains of NOC highlights the interdisciplinary effort required to successfully transform Maternal and Neonatal Health (MNH) services in rural Nepal.

The Availability of Emergency Obstetric Care in Birthing Centres in Rural Nepal: A Cross-sectional Survey.

OBJECTIVE: The purpose of this health system's study is to assess the availability of Emergency Obstetric Care (EmOC) services in birthing centres in Taplejung District of eastern Nepal. METHODS: A cross-sectional survey was conducted in 2018 in all 16 public health facilities providing delivery services in the district. Data collection comprised: (1) quantitative data collected from health workers; (2) observation of key items; and (3) record data extracted from the health facility register. Descriptive statistics were used to calculate readiness scores using unweighted averages. RESULTS: Although key health personnel were available, EmOC services at the health facilities assessed were below the minimum coverage level recommended by the World Health Organisation. Only the district hospital provided the nine signal functions of Comprehensive EmOC. The other fifteen had only partially functioning Basic EmOC facilities, as they did not provide all of the seven signal functions. The essential equipment for performing certain EmOC functions was either missing or not functional in these health facilities. CONCLUSIONS FOR PRACTICE: The Ministry of Health and Population and the federal government need to ensure that the full range of signal functions are available for safe deliveries in partially functioning EmOC health facilities by addressing the issues related to training, equipment, medicine, commodities and policy.

It Takes More than a Village: Building a Network of Safety in Nepal's Mountain Communities.

Purpose This report from the field details the ways that one small maternal child health NGO, which began its work in Tibet and now works in the mountain communities of Nepal, has established a model for integrated healthcare delivery and support it calls the "network of safety." Description It discusses some of the challenges faced both by the NGO and by the rural mountain communities with whom it partners, as well as with the government of Nepal. Conclusion This report describes and analyzes successful efforts to reduce maternal and infant mortality in a culturally astute, durable, and integrated way, as well as examples of innovation and success experienced by enacting the network of safety model.

Non-surgical interventions for pelvic organ prolapse in rural Nepal: a prospective monitoring and evaluation study.

OBJECTIVES: Pelvic organ prolapse (POP) is a major cause of morbidity in Nepal, particularly affecting women in the rural communities. Women with POP in Nepal may suffer from symptoms for decades. At present, the Government of Nepal advocates surgical intervention but access to surgical care is inadequate. This report evaluated the feasibility of a non-surgical public health programme in rural Nepal, and describes risk factors associated with POP in this setting. DESIGN: Prospective monitoring and evaluation study of a new public health programme. SETTING: Baglung district, rural Nepal. PARTICIPANTS: Women with gynaecological symptoms of POP. MAIN OUTCOME MEASURES: Risk factors for disease progression were assessed using Fisher's exact test, Pearson's χ(2)-test and logistic regression analysis. RESULTS: Of the 74 women included in this analysis, 70.8% were diagnosed with stage 2 POP or greater. The majority of women did not have any further children following the onset of POP symptoms (63.5%). Duration of symptoms ranged from 2 months to 60 years, with 73.4% of women suffering for over 5 years and 28.4% suffering for over 20 years. Univariate analyses identified age at screening, age at onset of symptoms, the duration of symptoms and an associated rectocele as factors associated with increasing POP severity (p < 0.05). Kegel exercises were taught to 25 (33.8%) women with POP and ring pessaries were offered to 47 (63.5%) women with POP. CONCLUSIONS: Non-surgical interventions may provide an opportunity to address the significant burden of POP in rural Nepal.