Khotang is the nearest remote district to Kathmandu located Northeastern Nepal. This is a hilly region with very limited access to any road or any infrastructure. It has a population of 206,312, 53% being women and women with 5,000 pregnancies per year. The rate of childbirth with a skilled birth attendant, the single most effective intervention to reduce maternal mortality, is less than 25%. Most facilities lack power, running water and are under-staffed. Estimates of maternal and neonatal mortality are twice the national average. There is gender imbalance in the districts with high rates of seasonal migration.
Khotang has one District Hospital, 2 primary health centres, 10 health posts and 63 sub-health posts. health facilities are meant to be staffed by 333 personnel, but over a third of these posts (126) are vacant. The District Health Officer and Family Planning Office in district health office (DHO), Khotang are also vacant. The district has a low contraceptive prevalence rate (44%). Only Disctrict Hospital provides free Safe Abortion Service (MVA+MA). However, recently service providers from two PHCs and seven health posts have been trained on Comprehensive Safe Abortion. But, the services have not started yet from those PHCs and health posts.
Recently, an incident occurred resulting death of a woman due to severe complications from abortion service. A mother of seven children from rural Khotang accessed MVA from district hospital. The hospital was not able to immediately send/refer the client to Kathmandu or nearest districts for further treatment. The women died. This is due to inaccessible road. The district has three airports but due to bad weather the client was not able to be chartered in plane or helicopter. The situation is worse as women in Khotang use traditional methods and herbal remedies for terminating their pregnancy. Also, the district has unregistered providers providing abortion service through pharmacies and selling unauthorized drugs to women. There are more PAC (Post Abortion Care) cases in district hospital.
According to Surendra Budhathoki, focal person from DHO- Khotang shared that there is prevalence of child marriage, high number of rape cases and the district is one of the top ranked when it comes to suicide. He also shared that the people are not aware of importance of family planning. Because of when women have to suffer and continue her pregnancy for 10th or 12th times. Married and unmarried, both access abortion service from district hospital. There is limited knowledge among villagers on legality of abortion and availability of family planning. Myths and misconception is the barrier for women to use family planning devices. Modern methods are still stigmatized. On asking him about stigma associated with abortion in the village, he shared that the community is not sensitize in abortion issue therefore people think it is a sin. However, people are also positive about free services available in health facilities and if needed they do visit and access service.
Surendra Budhathiki continued sharing about Christianity influencing villagers. There was only 2% of Christian residing in the village as per 2011 data. The trend is converting poor villagers into Christianity and its being challenge for health workers to convince the community to use contraceptives and access safe abortion services. Health workers are not allowed to conduct awareness campaigns regarding family planning and abortion in those communities. He said that last year, services providers from health posts were selected for Comprehensive Abortion Care training organized by Government of Nepal. One of the female service providers back out from the training as she is a Christain. She shared she is not allowed to even talk about abortion in her religion. Even if she wants her family won’t except her. She was afraid to be boycotted from her community.
The only reliable health workers to reach women in rural communities of Khotang with information on family planning and safe abortion are Female Community Health Workers (FCHVs). The DHO is under staffed and the team is not able to mobilize FCHVs in the communities. The team was only able to conduct 1 sensitization session for 40 people from different communities on “Free SA” service. “This is not enough”- said Surendra Buddhathoki. The district is also politically sensitive. Political pressure and influence are the biggest barriers for organizations and projects to implement programs effectively. Organization like PLAN International Nepal and project like SAAFAL were prohibited to continue their work in the district. The political instability, inaccessible road, under-staffed health facilities and religious beliefs are affecting the health of women. Women have to continue their pregnancy and give birth to more than 5 children degrading their health.
Nepal just conducted its district level election and all new bodies are on the board. The agenda for each and every rural municipalities must be advocating for women’s sexual and reproductive health rights. The priorities for health agenda could be meeting unmet need of family planning and accessible safe plus legal abortion service. The Government should give importance to mobilizing local qualified people as the district is under staffed. People outside of districts hesitate to travel and work in rural areas therefore, local human resources should be empowered.