Improving health service, access to education and nutrition status for women and children in far Western Nepal
Recently, PHASE Nepal started a new integrated community programme in 8 communities in Bajura (Rugin, Bichhaiya) and Mugu (Dhainakot, Kotdanda, Hyanglu, Ruga, Natarphu, Photu). The programme is co-funded by Austrian Development Cooperation – through EcoHimal Austria – and is running simultaneously with a livelihood improvement programme in Mugu, funded by Innocent Foundation and States of Guernsey. Mugu District is in the mountainous north-western Karnali region of Nepal. Accessed only by mud tracks or by air, Mugu has some of the lowest Human Development Index outcomes nationally, with the district ranked 67 out of 75 in 2011. Its small mountain villages have few or no basic services, meaning that many children are malnourished, maternal health is poor and its people are vulnerable to health problems such as diarrhoea.
To start the project and make a detailed assessment of the situation in the villages, a baseline survey was carried out by trained PHASE staff conducting door-to-door interviews of women in the six VDCs identified for the project, covering a total of 24% of households. The baseline survey covered three topics – maternal and child health, access to food and farming productivity, and women’s skills – by measuring a number of different indicators within these areas. A total of 542 women were surveyed in the project region in December 2015. Over two-thirds of those surveyed were aged between 20 and 31 (67%), with a further 7% aged under 20 and the remaining 26% over 31. The average household size was 7 with an equal split between male and female.
Maternal and child health
In Mugu, as with many regions of Nepal, mortality rates are very high among children and women of childbearing age. Neonatal deaths are often attributed to lack of access to ante-natal and post-natal health services for women, as well as factors such as malnutrition and anaemia in breastfeeding mothers.
Some outcomes from the survey regarding breastfeeding, weaning and care for newborns:
- Only 30% of the children in the 6 surveyed communities were exclusively breastfed until 6 months (which is recommended by World Health Organization)
- 63% of mothers knew about super-flour porridge as weaning food, though only 39% have actually used it. Super-flour porridge is made from finely ground roasted cereal grains and pulses and is one of the most nutritious options available; PHASE health staff teach mothers how to make this.
- Newborn care: 92% of those surveyed who responded to this question were able to name some of the necessary steps of taking care of a new born baby: drying and wrapping the baby in warm clothes or putting the baby onto the mother’s naked skin or chest.
- Care of the umbilical cord: 86% of those surveyed who responded to this question across the region mentioned either using a clean razor blade or knife boiled in hot water to cut the cord. Only 20% of those surveyed who answered this question mentioned the need to use antibiotic or Chlorhexidine cream on the cord.
- 62% of those surveyed believed that a new born baby should be bathed within the first 24 hours of birth. Traditionally, Nepalese women bathe a new born baby before wrapping it in clean clothes. Hypothermia, often caused by early bathing, is a major contributing factor for newborn health problems and death. The national recommendation in Nepal is to not bathe a newborn until 24 hours after birth.
Measuring the Mid-Upper Arm Circumference (MUAC) of young children is a widely used indicator of growth and nutritional standards by international organisations. Readings under 12.5cm are considered to indicate acute malnutrition, with children between 12.6cm and 13.5cm at risk of malnutrition. The MUAC measurement requires little equipment and is easy to perform even on the most debilitated individuals.
In our survey, 936 children between 6 months and 5 years had their mid-upper arm measured. Of the children measured, only 47% had a healthy MUAC of 13.5cm or above. 32% had a measurement ranging between 12.6cm and 13.5cm and 17% measured between 11.6cm and 12.5cm. Moreover, a small percentage, 4%, measured a circumference of only 11.5cm or less.
The survey worryingly shows that more than 50% of children surveyed are either at high risk of malnutrition or are clinically malnourished. Children who are at risk of malnutrition very quickly fall into the overtly malnourished group when suffering trivial childhood illness such as diarrhoea or viral illness such as measles, chicken pox, etc. 21% of the children surveyed were significantly malnourished, 4% suffering from severe malnutrition, which represents a life threatening condition.
Access to food and farming productivity
In Mugu malnutrition is a major issue leading to higher than average health care needs, susceptibility to illness and mortality rates. Our experience of working in this region suggests the reasons for poor health and high mortality are complex, but the biggest factors include chronic hunger, related to poor yields and lack of nutritious food; poor childhood feeding practices and low levels of productive and efficient farming techniques. Trading is extremely challenging in Mugu due to lack of road access, distance and terrain; families are dependent on the food they produce.
Some results from the baselines survey:
- A significant majority of those surveyed did have a kitchen garden (70%), whilst 30% did not. Our experience in the field shows that these kitchen gardens are usually not very extensive and do not yield produce all year round.
- 6% of families have between 1 and 5 mules at home. None of those surveyed kept more than 5 mules. 62% of those surveyed did not own any chickens. The majority of chicken-owners only owned between 1 and 5 chickens. Over half of those surveyed did not own any goats at home and 16% owned between 1 and 5 goats. 74% of those surveyed owned between 1 and 5 cattle at home. Only 2% did not own any cattle and 20% owned more than 6. The vast majority of those surveyed owned between 1 and 5 buffalo (87%). 13% of those surveyed did not own any buffalo. None of those surveyed owned more than 5 buffaloes.
- Only 6% of those surveyed are able to feed their families for 9-12 months each year from food they produce. The majority (60%) can only rely on their produced food to provide for their family for 3-6 months, and 31% only have enough produce for 6-9 months of the year, meaning that food must be sourced elsewhere to feed the family.
Of the 542 women surveyed in Mugu only 6% had achieved the School Leaving Certificate (equivalent to GCSE’s in UK) and 30% of the women were completely illiterate.
Based on this survey, it is clear that support to these communities in Mugu is essential. In every community, 2 PHASE Nepal health workers will be supporting the existing health services. Adult literacy classes will be conducted and livelihood improving activities as distribution of seeds, irrigation techniques and training on animal breeding will be part of this 3-year project.