Babita Shrestha, 20, received a warm bag when she gave birth to her daughter. Nurses showed her how to use the cloth in the bag to wrap the infant.
LALITPUR, NEPAL – Nirja Dhakal caresses her newborn daughter and smiles despite residual pain from her recent labor. She brushes her long, dark tresses from her face, revealing the red tika on her forehead, as she leans forward to nurse her baby.
Dhakal, 33, is recovering from the birth of her second child at Lubhu Primary Health Care Centre in Lalitpur district, about 5 kilometers (3 miles) from Kathmandu, Nepal’s capital.
Dhakal gave birth to her first child, a daughter, at home four years ago. Her husband was with her, and neighborhood women helped with the birth. At their suggestion, she wrapped her newborn in an old piece of fabric after bathing her.
“I was thinking of giving birth to my second child at home as well,” she says. “But when I found out the government had provisioned for free warm bags for delivering a child in health post, I walked here from my house when my labor started.”
The Nyano Jhola, or Warm Bags, program provides a bag containing clothes for mother and baby to women who deliver at government health clinics.
Dhakal could not afford to buy new clothes for her newborn, she says. She does not work but relies on remittances from her husband, who went to Qatar six months ago to work as a restaurant cook. She has no other family living nearby. She had planned to wrap her second newborn in old clothes before she read about the Warm Bags program.
“I express my gratitude to the government of Nepal for helping me and other hundreds of mothers like me who cannot afford new clothes for their newborn,” Dhakal says.
The bag contained a gown for Dhakal, a wrapping cloth, and two sets of baby clothes, including traditional Nepalese garments, a cap, socks, mittens and a vest.
Dhakal also received free medical care for her childbirth, iron pills to treat her anemia, vaccination for her child, and 1,000 rupees ($10.50) to cover the cost of her bus trip to the clinic. The government’s Safe Motherhood and Newborn Health program provided these benefits.
Dhakal felt safe and cared for when she delivered her second child at the clinic, she says. She had not known about the free services the first time she gave birth.
“When I had my first child, I felt like the pain would kill me,” she says. “But during my second delivery in the hospital, I was confident that the nurses would save me and my baby. Seeing the nurses in white dresses, I felt secure at the hospital.”
The government reports that its Warm Bags program has increased the number of women coming to health care and birthing centers by half. The program aims to encourage women to deliver at these clinics to reduce the risk of infection, pneumonia, and maternal and newborn death. Some mothers and nurses confirm the program has drawn women for deliveries, but others cite shortcomings that they argue make it ineffective.
The Family Health Division of the Ministry of Health and Population launched the Warm Bags program in August 2013 as an added incentive to the 2005 Safe Motherhood and Newborn Health program.
The division implemented the Warm Bags program at health care and birthing centers in all 75 districts, says Badri Nath Gyawali, undersecretary of the division. Nepal’s 1,800 birthing centers are government-run clinics that provide free care in rural areas. Health centers are small clinics that provide general health services and education.
Nepal’s government allocated 180 million rupees ($1.9 million) for the project for the 2013-2014 fiscal year, says Kiran Regmi, director of the Family Health Division.
Every month, 25,000 mothers receive warm bags, Gyawali says. Production and distribution of the clothes costs 800 rupees ($8.40) to 900 rupees ($9.45) per bag. The cost is higher in mountainous areas, where transportation is more difficult.
“The project is successful, as the number of women giving birth at the birthing center has increased by 50 percent within the first nine months of project implementation,” Gyawali says.
Gyawali cited data collected informally from birthing centers. The annual report scheduled for release after the 2013-2014 fiscal year ends in July will provide official figures.
Nepalese society still upholds the traditional birthing system, Gyawali says. Rural Nepalese women give birth in conditions that pose hazards to mothers and newborns. They deliver using kitchen knives, household equipment, dirty fabrics and bare hands, all of which can lead to infections.
“Most of the Nepalese women are unaware about maternal health,” Gyawali says. “It is difficult to attract them to the hospital only through awareness. So the government introduced the Warm Bags program.”
In addition to giving women an incentive to deliver at clinics, the Warm Bags program aims to protect mothers and their newborns from infections from contact with unsanitary clothes.
Newborns delivered in homes are often not cleaned properly or sufficiently wrapped, Regmi says. Unsanitary clothing increases the chances of navel infection, pneumonia and fever. Some newborns die of exposure to cold.
Most Nepalese women who do deliver their babies at health institutions in rural areas come without clothes for their newborns, Gyawali says. The rest bring old, dirty clothes in which to wrap their babies.
Neither Gyawali nor Regmi could provide data on infections.
Maternal deaths declined 6.1 percent from 2000 to 2013, according to a World Health Organization database report sourcing data from WHO, the World Bank and U.N. agencies. As of 2013, 190 of every 100,000 live births in Nepal resulted in a mother's death.
Infant deaths – those that occur within the first year of life – decreased 28 percent from 2001 to 2011, according to the 2011 Nepal Demographic and Health Survey. There were 46 infant deaths per 1,000 live births as of 2011.
Regmi says preliminary monthly reports from government-run health institutions indicate that the Warm Bags program has sparked further progress. Official data will be available after the fiscal year ends in July.
“Pregnant women come to the birthing center for the Warm Bags, and hence the maternal and infant mortality rate has decreased significantly,” she says.
The Safe Motherhood and Newborn Health program is part of the government’s strategy to reduce the infant mortality rate to 16 per 1,000 live births and the maternal mortality rate to 134 deaths per every 100,000 women giving birth by 2015 as part of the U.N. Millennium Development Goals, Gyawali says. The global goals include reducing child mortality by two-thirds and reducing maternal mortality by three-quarters.
Rural health care centers also report results from the Warm Bags program.
“Every month, two to four pregnant women used to come here for their delivery,” says Lumbini Shakya, a staff nurse at Lubhu Primary Health Care Centre in Lalitpur district. “But nowadays, the number has increased to two to four pregnant women per day. This is all due to the Warm Bags program.”
Sukumaya Manandhar, 21, had her first child at the Lubhu Primary Health Care Centre in April because of the Warm Bags program, which she had heard about from a neighbor.
“I am so happy to get such clothes because otherwise I am unable to buy such clothes,” she says.
But the Warm Bags program has faced challenges, including insufficient budget and staff, Regmi says. The program also has had trouble delivering the bags to health centers in remote areas with poor road access.
Purna Kumari Bhusal, a staff nurse at Lele Primary Health Care Centre in the Lalitpur district, recommends adding full sleeves to the maternal gown and making the newborn clothes bigger so infants can wear them longer.
“The clothes in the warm bag are made up of rough fabrics and are of low quality,” she adds.
Sometimes, the offer of free clothes is not enough to persuade mothers to deliver at clinics.
Mina Acharya, 23, gave birth to both of her children at home in Lalitpur district.
"I did not go to the health care center for delivery because I did not believe there are skilled health workers and doctors,” she says. “I was not certain whether the nurses would provide a good service or not."
Warm bags are not the best solution, she says.
“It is better to create awareness about maternal health than to give incentives to bring rural people to hospitals," she says.
Regmi and her team plan to expand the Warm Bags program in the fiscal year that begins July 15.
“To make the project more effective, it will be taken to the big hospitals from the next fiscal year,” she says.
GPJ translated this article from Nepali.
