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 i 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. ii 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. iii 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 iv 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 v 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 vi vii