No Way There
“Can’t find a way there,” the computer woman says plainly when we pull up the GPS and enter Biratnager to Okhre, Nepal.
She should have an asterisk next to that phrase. Just because she can’t find a way there doesn’t mean we’re not going to try. We pile in the Land Cruiser and roll down the windows. The dust from the Nepali roads catches in our throats as we begin our journey. Two of us in the front, three in the back; gear, water, and luggage piled around us. Our destination is 49 miles as the crow flies, but 10 hours as the Cruiser drives, up and over the switchbacks.
The roads over the Himalayan Foothills of the Bhojpur region are steep and unpaved – they are also the only way in and out of the area. Photograph by Erica Baker
As we follow the natural twists of the land, there is no barrier between us – the travelers – and the thousand foot drop just steps away. Each hairpin bend, each steep precipice, is a reminder that the terrain is Nepal’s most stunning and most stubborn characteristic.
Our Cruiser stalls in the thick mud, inches from the plunging edge. Downshift, fish tail, lurch, move forward. For 10 hours. The deeper we go into the mountains, the more challenging the terrain becomes.
This is plain life, navigating the mountains of Nepal.
Every day, pregnant women in Nepal go head to head with this terrain. While medicine in Nepal has evolved, infrastructure has not. To safely deliver a baby under the care of a medical professional, Nepali women must battle the dirt roads and mountains, which stubbornly hold their ground.
A women poses with her young baby in her village. Photograph by Erica Baker
One young mother is 39 weeks pregnant. The baby is coming now and she needs a nurse’s care. She and her husband prepare for the journey. They have two options. They can walk seven hours to the nearest district hospital. Or they can take a four hour bus ride.
Keep in mind there is no other option, no alternate route. There is no way to tell if it’s raining on the other side of the mountain, or whether the road is already awash in mud. If they take the bus, they accept this uncertainty. They accept the bruising bumps and jolts that jostle the most able person, let alone a pregnant woman. They accept the risk that the bus might stall, still hours from the hospital. If it’s during the three-month monsoon season, the already dangerous terrain becomes impassable.
It’s here in this wild place with deep canyons and abrupt peaks that One Heart Worldwide is creating an alternate route – a network of safety that laces itself right through the middle of the terrain to ensure that each mother and child has a chance for health.
Sangita Rai (19) sits on a bench with her husband and newborn son as they wait for family to arrive at the birthing center to carry her home on a stretcher. She arrived the previous morning at 11am after walking two hours to the birthing center and gave birth to her son four hours later. Photograph by Erica Baker
If you can't beat the terrain, you work with it.
Their mission is simple: end all preventable deaths related to pregnancy and childbirth worldwide. And they focus on women who are most vulnerable simply because of where they live.
This is the first lesson in nature-imposed limits: If you can’t beat the terrain, you work with it.
It’s daylight when we arrive in Okhre, one of the most remote and underdeveloped places on the planet. The village’s idyllic stone and timber huts with woodburning stoves overlook jaw-dropping views. Cascading rice farms, plush green plummets, and plumes of clouds have their moment in the golden light of the setting sun before the evening fog takes over.
We’re on the top of a mountain, the kind where you feel you can reach out and touch the sky.
“You see that, all the way over there?” asks Krishna Dangi, Communications Officer at One Heart Worldwide. He points to the other mountain. “That’s where the Bhojpur District Hospital is.”
We’ve just come from there – a treacherous four hour trip by Land Cruiser. I imagine a woman in labor making the same journey on foot.
The people of the 500 or so households of Okhre live a simple life. Some get water from storage reserves on their properties. Others gather it from local streams. Some have electricity – although unreliable – and others live by lantern light. They live off of their land, making traditional Nepali dal-bhat out of rice, potatoes, fermented kale, cauliflower, and chicken with a mixture of coriander, turmeric, garlic and chili. This is life in the village.
Portraits taken on the streets of Ohkre.
We’re here because Okhre is home to one of One Heart Worldwide’s maternal and neonatal health programs, the home base of which is a bright orange and green birthing center set squarely in the middle of the village. It welcomes women from the community for neonatal checkups and labor and delivery.
Someeta is a nurse at the birthing center. She’s smiling as she shows us through the delivery room and the family waiting room. Inside the birthing center electricity flows, powered by generators. It’s stocked with modern medicines and stainless steel instruments. Checklists hang on the walls reminding the staff of protocol and health standards.
Across the street from the birthing center, women line up by the dozen for ultrasounds, provided by Someeta, who is trained to do preventative screenings. Some of the women live nearby. Others have walked an hour, down the meandering dirt roads. This small section of the town is alive with energy.
It wasn’t always like this.
Someeta remembers a time when the women of Okhre refused to use the health facility.
“It was cold and deteriorating,” said Someeta. “Nowhere for families to wait.” It didn’t have proper resources. There was no delivery room. It wasn’t stocked with medicine.
If the pregnant women of Okhre needed medical care or wanted preventative screenings during their pregnancy, this is the last place they would have come. They would travel to the nearest district hospital, the one Krishna pointed to.
It’s because of scenarios like this that infant mortality rates have been abysmal in the most remote areas of Nepal. Where no program like One Heart Worldwide exists, about 90% of babies are delivered in a home setting without a skilled birthing attendant. The maternal and neonatal mortality rate is five times the national average of Nepal – among the highest in the world. From a medical perspective, most of those fatalities are preventable. The mothers and babies just need access to preventative screenings, medicine and skilled birthing attendants.
Pregnant women wait outside the Birthing Center for their ultrasounds and birth class. Many of the women have walked several hours for their appointments. Photograph by Erica Baker
Accessibility has always been the regions' biggest challenges. When you’re in one of the most underdeveloped places in the world, you can’t get anywhere quickly in an emergency. Preventative or routine needs? Forget it.
Where One Heart Worldwide has successfully established birthing centers and programs, however, the rate of deliveries with a skilled birthing attendant has more than doubled and neonatal deaths have dropped significantly (in one area, only two maternal deaths and nine neonatal deaths were reported in a year, compared to 15 maternal deaths and 91 newborn deaths five years prior).
One Heart Worldwide is trying for the same success rates in the village of Okhre, where the program is in the second phase of implementation.
Already, they are seeing great success.
Sangita Rai, Nurse and Skilled Birth Attendant, teaches a class on safe pregnancy and birth. Photograph by Erica Baker
One Heart Worldwide initiated a renovation of the facility, trading dark rooms and hallways for more light and bright colors. They made sure it was stocked with medicines and supplies. They created comfortable rooms for family members awaiting the birth of a child or grandchild. One Heart Worldwide trained nurses in the community to become Skilled Birthing Attendants, including Someeta, and established criteria to bring the facility up to international standards.
Before One Heart Worldwide arrived in Okhre, there were zero deliveries within two years in that facility. This year alone – with 2 months left in their calendar year – 87 babies have been delivered.
"I can’t tell you how happy we were for that first baby born in that birthing center. Sometimes 87 deliveries is amazing," said Pratiksha Rai, Training Officer at One Heart Worldwide, "Other times it's just one."
Someeta Limbo, a nurse and skilled birth attendant delivers Sangita Rai’s (19) baby boy in the labor and delivery room at the birthing center. Photograph by Erica Baker
The first birth after the new program has been established is an incredible milestone and a big hurdle to cross.
“Members of our community say it looks better than the district hospital,” Someeta beams shyly . “They are proud.”
Someeta’s training has given her the confidence to handle complicated pregnancies and save lives.
“I remember a mother who home delivered but rushed to the birthing center for delayed placenta. The mother was almost unconscious. It was an emergency situation, but I was confident in how to treat it,” she said. “I saved the life of the mother.”
A Network of Safety
The Dalai Lama asked a question, which set in motion this business of saving the lives of mothers and their newborns. Arlene Samen, Founder and President of One Heart Worldwide, remembers well the moment the question landed in her life.
A nurse practitioner in maternal fetal medicine, Arlene traveled to Tibet as a medical volunteer. She had the opportunity to share her work with the Dalai Lama, where he confided in her that his own mother had lost seven of her sixteen children in childbirth. Then, simply and softly, he asked Arlene to help the women and children in Tibet.
“It was completely transformational,” said Arlene. She took the charge and set up One Heart in Tibet to train local health providers, community members, families, and mothers in safe birthing practices. Over 10 years, One Heart worked in Tibet with great success until political pressures made it difficult for them to continue operations. They turned the program over to a local team and expanded their operations to other areas in needlike Nepal.
Nabina Rai poses for a portrait next to her home in Okhre. She gave birth to her first baby at home, but she decided to deliver this baby, her second, at the birthing center. Photograph by Erica Baker
“During our time in Tibet, I learned that we can’t promise to be somewhere forever,” said Arlene. “There’s so much we can’t control, including political pressures. We are always striving for local sustainability.”
Long-term sustainability is one goal that many nonprofit organizations set aside, mostly because it’s really hard. If you want to solve health problems long-term and do so by empowering the local community to eventually own the program, you need to take a holistic approach.
"One approach is not enough," said Arlene. "So we put a system in place so we can address all elements and create real change."
LEFT: A nurse performs an ultrasound on a woman in labor at the Bhojpur District Hospital. RIGHT: A newborn rests at Bhojpur District Hospital. Photographs by Erica Baker
The Network of Safety model is the heartbeat of One Heart Worldwide today. The model acknowledges all of forces that impact the health of mother and babies – cultural pressures, government systems, political realities, resources. Rather than try to overpower them, the model seeks to integrate with them. The overall action plan is a one year program of set up (phase 1), three years of program implementation (phase 2), and two years of support and transition to local government (phase 3).
It’s a model that takes a great deal of planning and intention. The One Heart Worldwide team is constantly relationship building, understanding of the community and culture, and understanding political tensions and government realities.
At every step, One Heart Worldwide involves the community. When they raise funding for health facilities, they first work to garner community support. For example, 35% of the Okhre birthing center was funded by the local community. They look for local nurses and doctors who want additional training. Training courses provide knowledge and critical skills so medical professionals can make life saving decisions. Dr. Pujan in the Bhojpur District Hospital completed the training course sponsored by One Heart Worldwide. Today, he is able to offer emergency c-sections, each surgery a reminder of lives that would have otherwise been lost.
Dr. Pujan delivers a baby via cesarean section at Bhojpur District Hospital. Photograph by Erica Baker
Over the past eight years, One Heart Worldwide has successfully piloted the Network of Safety in 18 districts. Two have reached sustainability. Others are at various phases of implementation.
"Eventually we will have to go where there is greater need," said Arlene. "So from day one we are also working with the government for sustainability."
35% of the Okhre birthing center was funded by the local community.
One Heart Worldwide’s programs are designed specifically to go hand in hand with government maternal and neonatal programs. The Nepali government pays the salaries of the local medical professionals, but One Heart Worldwide provides the special training for skilled birthing attendants and c-sections. To increase deliveries in medical facilities, Nepal has introduced a cash incentive program for all women in Nepal. One Heart Worldwide helps educate families about the program.
LEFT: Dr. Pujan checks on a woman in labor at Bhojpur District Hospital. RIGHT: Nurses clean a baby after birth via cesarean section at Bhojpur District Hospital Photographs by Erica Baker
The Mayor of the greater Bhojpur region, of which Okhre is a locale, said the community has seen positive changes since One Heart Worldwide arrived, including a better understanding of how to allocate dollars to best benefit the community in terms of health outcomes that trickle down across the economy.
“We can see institutional change and are working on ways to continue to replicate these activities in the years to come,” said the Mayor.
"We ask the [government leaders] ‘what are your needs?’ And health is usually not their first answer. They don't know the impact health has on the community as a whole," said Surya Bhatta, Acting Executive Director of One Heart Worldwide. “Our job is to coach them.”
LEFT: Mayor of the Greater Bhojpur Region MIDDLE: Surya Bhatta, Acting Executive Director of One Heart Worldwide RIGHT: Jeevan Ghimire, Minister for Social Development
The successes of the partnership are seen at all levels of government. Nepal's Minister for Social Development Jeevan Ghimire noted that “the government is not an expert in every sector of maternal and neonatal health. Nonprofits are very welcome to work alongside the government, but they cannot implement the program directly, so they have to work with local authorities. We need this partnership to make our health system more accessible and modern.”
"We create the environment to give them momentum," said Surya.
But it’s not just the government and birthing centers providing momentum. It’s the community members themselves.
Sangita Rai’s home sits just steps away from the Okhre birthing center. It’s enchanting – a garden on the rolling hills with avocado trees and scents of cardamom in the air and chickens wandering about. It’s speckled with foliage – pinks, reds, yellows, and purples.
In an open-air room with a kitchen table, she serves us coffee made with buffalo milk, and popcorn with half-toasted mustard seeds made over an open fire.
“She opens her home to the community,” says Pratiksha. “She has a whole medicine cabinet over there.” She points to a shed. “The community knows they can come to her for help.”
Sangita is a nurse at the birthing center and a skilled birthing attendant, thanks to the training sponsored by One Heart Worldwide.
Sangita Rai, Nurse and Skilled Birth Attendant, teaches a class on safe pregnancy and birth. Photograph by Erica Baker
She’s also the unofficial, unabashed village advocate. She sees Okhre’s needs and she fights for them. That cell tower up on the top of the hill? Sangita asked for it. Electricity cut off unexpectedly? Sangita makes calls until it’s turned back on. Medicines running low at the birthing center? Sangita is on the phone with local government officials demanding supplies. They arrive the next day.
Sangita Rai, Nurse and Skilled Birth Attendant, performs an ultrasound on Devi Sunar who is seven months pregnant with her second child. Photograph by Erica Baker
Every community needs people like Sangita to keep them moving forward. Call them advocates or activists or organizers. They make a difference. And One Heart Worldwide knows this. That’s the whole point. One Heart Worldwide creates momentum. They flow through the terrain, find the resources, empower the locals, and watch them flourish.
Sangita is a reminder of this. One Heart Worldwide is the catalyst. But it is the community – it is Nepal itself – who will lift itself and make sure women and babies have the medical care they need.
The Blue Sari
Gopi Sherpa’s blue sari is a sort of secret language – a code to the women in the village that they have an ally, someone to confide in. Someone who has answers. Gopi is Okhre’s Female Community Health Volunteer (FCHV) – a position established by the government to educate women about hygiene and disease prevention. And she’s a vital link between the women and One Heart Worldwide’s maternal and neonatal program.
Each day, Gopi leaves her home and walks the village fields to make home visits. She keeps record of the number of pregnant women and how many have received immunizations, and provides all the details about her ward to the health facility. Her ultimate focus is on safe motherhood and pregnancy.
Gopi also meets them once a month in Health Mothers’ Groups where each family is invited to send a female representative. Here, they talk about issues impacting women, in everything from finances, to safety, to health. The Mothers’ Groups give women a voice and they create an avenue for health education that is so essential to behavior change when it comes to health.
"The womens’ groups are really the backbone of the health structure," said Pratiksha Rai, Training Officer at One Heart Worldwide. "They are how we reach the mothers."
Gopi Sherpa, Okhre’s Female Community Health Volunteer, poses for a portrait in her fields while wearing her blue sari. Photograph by Erica Baker
"We want to make sure we're meeting their needs, not our needs," said Arlene. "That means we have to listen to their needs and know their needs."
One Heart Worldwide uses the FCHV and Mothers Groups to share experiences and encourage other women.
One Okhre mother remembers the birth experience she had when delivering her now 10-year-old son, before the birthing center was established: “It was very difficult to deliver in the home with the help of my mom,” she said. “At certain times, I felt like I was dying. I had a month of bleeding afterwards. It was not healthy.”
Pratiksha Rai, Training Officer at One Heart Worldwide, examines a newborn following his birth via cesarean section at Bhojpur District Hospital. Photograph by Erica Baker
Afterward, she learned about the birthing center and the benefits of delivering with a skilled birthing attendant through her FCHV and Health Mothers’ Group. She chose deliver her second baby – now two years old – at the new birthing center.
“There were many helpers there and I had access to everything,” she said. “And this time, I had no bleeding, because of the care of my nurse at the birthing center.”
One Heart Worldwide is the reason for the birthing center, but they don’t see it as their birthing center.
LEFT: A mother and child watch a street festival in Okhre. RIGHT: A mother holds her baby in her hospital bed while recovering from a cesarean section at Bhojpur District Hospital. Photographs by Erica Baker
"It's not our facility. It's for the community. It's all for their benefit. We want the sustainability," said Pratiksha. "We know One Heart Worldwide will remain in their hearts for long after we're gone.”
Their footprint on the terrain.