Practicing Good Medicine: A community-based diagnosis and

151 Pages·2011·1.08 MB·English

by  Liz Adler

Practicing Good Medicine:
A community-based diagnosis and prognosis for promoting obstetric care access and use in
rural Nepal

by Elizabeth Adler

Thesis submitted in partial fulfillment for the degree of BACHELOR OF ARTS in
DEVELOPMENT STUDIES

Brown University

April 15, 2011
by ELIZABAETH ADLER

……………………………………………………

First Reader
GEOFFREY KIRKMAN

……………………………………………………

Second Reader
STEPHEN MCGARVEY

……………………………………………………
ABSTRACT

Maternal health interventions are failing to reach the women who need care most.
Ninety-nine percent of women who die preventable deaths in childbirth live in developing
countries. Maternal mortality is the 21st century’s largest health inequity because health care
delivery systems are failing women in the developing world. In particular, women in low-
resource areas face obstacles in accessing and using essential obstetric care (EOC), the most
effective clinical intervention for reducing maternal mortality. As solutions remain out of reach
for these women, the need to design better health care delivery strategies and support EOC
uptake in the developing world is starkly evident. This thesis addresses that need in the context
of rural Nepal—an area with one of the world’s lowest rates of obstetric care uptake and highest
rates of maternal mortality. In doing so, this thesis asks two primary questions: what barriers do
rural Nepalese women face in accessing and using EOC, and what can be done to increase
accessibility and utilization of EOC among women in rural Nepal?

This thesis’s human-centered approach integrates local realities and community attitudes
into intervention design.
In response to the limited effectiveness of large-scale approaches, this thesis takes a human-
centered approach to health intervention design. The human-centered design framework grounds
problem definition and intervention design in community experiences and attitudes, supporting
context-specific, community-owned solutions. This thesis uses focus group discussions in
Jharuwarasi, Nepal to make an “EOC diagnosis” of factors that constrain EOC access and use for
rural Nepalese women. Based on this diagnosis, focus group discussion, analysis of past
strategies, and secondary evaluation reports inform an “EOC prognosis” that makes
recommendations for supporting EOC uptake in rural Nepal.

Obstetric care delivery failure is rooted in insufficient attention to local realities. Care delivery
models should leverage community ownership and involvement to support obstetric care uptake.
The EOC diagnosis illuminates four major obstacles to EOC uptake in rural Nepal: (1) lack of
proximity of EOC facilities, (2) high perceived cost of care, (3) doubts regarding quality of care,
and (4) social hierarchy within the health care delivery system. The diagnosis suggests that,
while macro-level health interventions have removed formal barriers to care, community
experiences and attitudes deeply influence care access and use. Thus, strategies of care delivery
must better incorporate local realities to close the gap between policy commitments and care
uptake on the ground. In response to the EOC diagnosis, the EOC prognosis makes three primary
recommendations rooted in local context: (1) bring birthing centers to the village level, (2)
incorporate community input to train a trusted cadre of skilled birth attendants, and (3)
encourage participatory monitoring and evaluation through women’s groups. Secondary
evaluation and promising practices from the past suggest that the local ownership, community
trust, and stakeholder participation inherent in this EOC prognosis design have the potential to
bolster EOC uptake.

Designing human-centered interventions represents an opportunity for global health and
development projects to respond more effectively to local context. Community-based approaches
can help close the gap between policy commitments and results on the ground.
Keywords: obstetric care, maternal health, Nepal, human-centered design
“If you have come to help me, you are wasting your time.
But if you have come because your liberation is bound up with mine,
then let us work together.”
-Lilla Watson

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Sometimes I imagine that pregnancy and childbirth is the leading cause of death for
women of reproductive age in my society as it is in much of the developing world. I see protests
(or perhaps more likely thousands of medical malpractice lawsuits)—people up in arms that
women should face such a risk of death simply for completing their reproductive functions. I
believe that women in other societies deserve that same outrage.
By some random combination of biology, geography, and cosmic luck, my life is not at
stake simply because I am a woman. I have reproductive choices and access to resources. Should
I choose to become pregnant, I do not face a significant risk of death. This thesis is for the
millions of women who are not so lucky. I hope that in some small way this thesis gives you a
voice.

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A.M.D.G.
ACKNOWLEDGEMENTS

My fieldwork for this thesis would not have been possible without the openness of the
people of Jharuwarasi, Nepal. Thank you for welcoming me into your community. Thank you
especially to the Kc family, for becoming my Nepalese family.
I am also deeply indebted to my thesis advisor, Geoffrey Kirkman. Thank you for your
practicality, honesty, and humor throughout this process.
Special thanks to Steve McGarvey, who not only acted as a second advisor for this thesis
but who has been a mentor to me over the past three years. Thank you for guiding my
exploration of global health and for instilling me with the values and the courage to act with
conviction along the way.
I don’t know if this thesis, or perhaps any Development Studies thesis, would have been
possible without Cornel Ban. Thank you for your tough critiques, which kept me working, and
your unending enthusiasm and support, which kept me going. The Development Studies program
at Brown is so lucky to have you.
Another integral part of this thesis project has been TEAM DS. I feel incredibly lucky to
be a part of the Development Studies undergraduate program at Brown because I am surrounded
by an amazing group of peers. To my fellow DS-ers, thank you for challenging my ideas, helping
me through this process, and being such wonderful friends. Special thanks to Colette DeJong and
Haley Jordahl for “thesis Tuesday,” which I think happened approximately once. And to Arielle
Balbus, my soul Mecca.
I am also grateful for Rachel Simon, the world’s best library partner. Thank you for your
inspiring dedication to people you don’t have to care about and for your wild incarcero-
feminism. Your friendship is so special to me.
Thanks also to my sister, Alexis Schrader, for editing this thesis. I so appreciate your
patience and kindness.
Finally, thank you to my parents, Jeanie and Eric Adler, for making me believe that I can
do anything—and reassuring me that I don’t have to do everything. Your love and support have
shown me firsthand why the world needs mothers, and fathers. I admire you, and I love you.

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TABLE OF CONTENTS
ACKNOWLEDGEMENTS..................................................................................iii
ACRONYMS AND ABBREVIATIONS.............................................................vi

Chapter One: The Opportunity to Listen............................................................1
INTRODUCTION........................................................................................1
RESEARCH QUESTIONS..........................................................................2
SIGNIFICANCE..........................................................................................5
THESIS STRUCTURE AND LIMITATIONS............................................8
LITERATURE REVIEW.............................................................................9
METHODOLOGY.....................................................................................27

Chapter Two: An Anatomy Lesson
Maternal health services delivery and EOC use in rural Nepal………………..33
INTRODUCTION......................................................................................33
BASIC ANATOMY...................................................................................33
MATERNAL HEALTH SYSTEMS ANATOMY.....................................35
CONTEXT..................................................................................................41
ANATOMY OF SERVICE USE................................................................46
PROGNOSES IN ACTION........................................................................48
CONCLUSION...........................................................................................53

Chapter Three: HEAR……………………………....................................…….55
CHAPTER OVERVIEW............................................................................55
EOC DIAGNOSIS......................................................................................58
LOCAL VOICES VS. GLOBAL VOICES................................................72
CONCLUSION...........................................................................................77

Chapter Four: CREATE......................................................................................80
CHAPTER OVERVIEW............................................................................80
EOC PROGNOSIS.....................................................................................83
CONCLUSION.........................................................................................106

Chapter Five: DELIVER...................................................................................112
INTRODUCTION....................................................................................112
CONCLUSIONS AND IMPLICATIONS...............................................116
DELIVER refined: AVENUES FOR FUTURE RESEARCH.................123
CONCLUSION.........................................................................................125

Appendices
APPENDIX A: Guiding Focus Group Questions....................................127
APPENDIX B: Focus Group Demographics...........................................130
APPENDIX C: Focus Group Logistics....................................................132
APPENDIX D: Coding Categories...........................................................133
APPENDIX E: Dissemination and Delivery of the Thesis Project..........134

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WORKS CITED.................................................................................................135

TABLES AND FIGURES

Tables
Table 1.1: EOC prognoses and their relevance in the Nepali context...................26
Table 2.1: Maternal health services landscape and EOC availability in Nepal....37
Table 2.2: Spotlight on SSMP, a comprehensive EOC prognosis..........................51
Table 4.1: Pitfalls and promise for EOC prognosis design....................................88
Table 4.2: How the EOC prognosis responds to the EOC diagnosis....................111
Table A.1: Focus group participant demographics..............................................131
Table A.2: Coding categories...............................................................................133

Figures
Figure 2.1: Timeline of major efforts to increase EOC access and use in Nepal...52
Figure 3.1: World Bank model of factors determining uptake of reproductive
health services…....................................................................................................73
Figure 3.2: Community-based model of factors determining uptake of EOC
in Jharuwarasi, Nepal............................................................................................74

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ACRONYMS AND ABBREVIATIONS
ANM: Auxiliary Nurse Midwife
BEOC: Basic Essential Obstetric Care
CEOC: Comprehensive Essential Obstetric Care
CCT: Conditional Cash Transfer
DFID: Department for International Development (UK)
DSF: Demand-Side Financing
EOC: Essential Obstetric Care
EmOC: Emergency Obstetric Care
FCHV: Female Community Health Volunteer
GDP: Gross Domestic Product
GHI: Global Health Initiative
GNP: Gross National Product
HCD: Human-Centered Design
IDS: Institute for Development Studies
MCHW: Maternal and Child Health Worker
MDG: Millennium Development Goal
M&E: Monitoring and Evaluation
MMR: Maternal Mortality Ratio
MRDP: Vietnam Sweden Mountain Rural Development
NFHP: Nepal Family Health Program
NGO: Non-Governmental Organization
NHRC: Nepal Health Research Council
NRS: Nepali Rupees
NSMNH-LTP: Nepal Safe Motherhood and Newborn Health Long-Term Plan
PM&E: Participatory Monitoring and Evaluation
SBA: Skilled Birth Attendant (also used to refer to Skilled Birth Attendance)
SDIP: Safe Delivery Incentive Program
SSMP: Support to the Safer Motherhood Project
UN: United Nations
UNFPA: United Nations Population Fund
USAID: US Agency for International Development
VDC: Village Development Committee
VHW: Village Health Worker
WHO: World Health Organization
WRLHP: Women’s Right to Life and Health Project

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