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profiles by mike field

SWARAJ RAJBHANDARI

Swaraj Rajbhandari takes a break from maternal and child health work to enjoy  her home garden.

When Swaraj Rajbhandari returned to her native Nepal last year after two and a half years working overseas, she found herself face to face with the great scale of one of the problems confronting women in her country. To the usual challenges inherent in improving child and maternal health in any developing nation, consider adding the world’s tallest mountains. “While it’s good to be back, I was reminded that our system of health care faces many obstacles,” says Rajbhandari, MBBS, MCPS, MPH ’99. “The country is very mountainous, and it is often impossible to get a woman to a health center in case of an emergency. There are also shortages of manpower, especially in remote areas. These women can’t get to a hospital in an emergency.”

Trained as an obstetrician/gynecologist, Rajbhandari now works as a reproductive health specialist charged with strengthening the government health system. Although her primary duties involve work at the national level in the capital city of Kathmandu, Rajbhandari has had the opportunity to see firsthand how topography can impede even the most ambitious plans for health care delivery.
“I was in Jumla, a remote district in western Nepal, where a team of 18 doctors and 12 nurses and other supporting staff went to do a health camp,” she says. “It was supposed to be just a GYN camp, but in the short time we were there I had one woman come in who was bleeding at term and we had to do an emergency cesarean [section], and another who had a ruptured ectopic pregnancy. It was purely luck that we were there. Otherwise, she would have died. In these remote regions, if the couple cannot afford to fly her to the hospital, the woman dies.”

In western Nepal’s remote Jumla district, local people gather for a health camp.

And yet, in the fight to save lives and improve health, it is not just the mountains but more familiar obstacles that Rajbhandari must overcome. “Factors impeding women’s health are the result of their relative low status in society, which leads to poor education, limited economic opportunity, and poor access to health care,” she says. “All of these issues fuel poor reproductive health outcomes. In Nepal our contraceptive use rate is less than 40 percent. We also have one of the highest rates of maternal mortality in the world. One of the leading causes of maternal mortality is unsafe abortions. To address this, we are implementing a comprehensive post-abortion care program to prevent unintended pregnancies and manage complications.”

Rajbhandari is working with the Nepal Family Health Program, a consortium of four major agencies working with the U.S. Agency for International Development on a five-year program to strengthen family planning and maternal and child health. She is employed by one of the co-partners, Engenderhealth, as a reproductive health team leader.

“I provide technical assistance to the Minister of Health,” says Rajbhandari, who was a fellow at the School’s Bill and Melinda Gates Institute for Population and Reproductive Health. “Our basic job is to ensure quality of service by providing on-site coaching, giving feedback to the districts, and supervising and monitoring family planning clinics.”

Increased use of contraceptives—primarily Depo-Provera injections—has decreased the average family size in Nepal to 4.1 children per family. That’s still high by developed countries’ standards but lower than it was previously. Rajbhandari’s goal is to bring improved reproductive health benefits to all Nepalese, regardless of the terrain. “It’s a big challenge,” she says. “Right now I’m involved in writing national standards and protocols and guidelines. But the most difficult part is to implement them at a local level. You try to take these new initiatives to an outpost where there is one guy who has to do everything. Often, he’s very happy to see us. But when we begin asking for statistics and telling him about the new programs and policies—well, it can go both ways.”