It was midnight when Kalpana and Rohit Agri had to take their three-day-old daughter, Kritima, to Bardiya hospital in western Nepal. She was listless and, despite the antibiotics she’d been prescribed, had developed a high fever. Hearing her struggling to breathe, they woke a neighbour to take them.
Kritima was admitted with life-threatening neonatal sepsis, probably an infection she had picked up in the hospital where she was born.
A recent Lancet paper found that infections acquired in hospitals are the third-biggest contributor to antimicrobial resistance. And as superbugs spread and antibiotic resistance rises, more children are at risk.
According to the World Health Organization (WHO), sepsis and meningitis account for 15% of global neonatal deaths.
In Nepal, 3.5 million people still lack basic access to water while 11.3 million do not have use of a decent toilet.
This week, minsters at the World Health Assembly in Geneva will debate a resolution to ensure adequate water, sanitation and hygiene (Wash) are provided in health facilities. More than 1.5 billion people use health centres that lack decent toilets, according to global estimates compiled by the WHO and Unicef.
Two years ago, Bardiya hospital opened a ward to deal with all but the most complicated cases of sepsis. More than 200 babies have since been treated. The demand is constant. Last year, more than 1,000 babies were delivered at the 55-bed hospital.
“Typically, two to three women give birth here daily,” says Sangita Regima, a senior nurse who underwent special training to deal with sepsis. “But we can have up to eight women here in labour at once.”
With the arrival of federalism in Nepal and the 2015 constitution setting out citizens’ rights, there have been rapid steps forward in sanitation. In 1990, coverage was just 6%; today, following campaigns to eliminate open defecation, it is 99%.
Since decentralisation, the country has been reorganised into 753 municipalities, seven provinces and a slimmed-down central government, explains Lal Bahadur Shrestha, mayor of Badhaiyatal. Municipalities can raise their own taxes and develop their own policies, providing they are true to the spirit of the constitution.
Shrestha now plans to open five new health centres and a tiny hospital in the area, part of 2,500 health facilities the central government has approved for rollout over the next two years. Finding medical professionals and trained, well-equipped cleaners for these centres will be a challenge.
Just half of heath facilities in Nepal have both water and soap available, and only a quarter have disinfectants or sanitisers. The government has long supported infection control, but there are still gaps in provision.
The medical staff in Bardiya are efficient. Regima bustles between the two newborns supporting the mothers as they breastfeed. The importance of good hygiene permeates everything the staff say, but the grim reality of the lavatories by the maternity ward may just explain why a baby like Kritima, who was only just below average weight at birth, might succumb to such a dangerous infection.
Nepal’s healthcare is moving in the right direction, says Dr Subhash Pandey, medical superintendent at Bardiya hospital Antibiotic prescription is not confined to doctors, he says – anyone can walk into a pharmacy and ask for them.
Research has shown a high correlation between people paying for medicines over the counter, which is common in low-income countries, and rising resistance. The course may not be followed properly and Pandey and colleagues take account of this when prescribing for stubborn infection.
Article 35 of the constitution on the right to health grants each citizen access to clean drinking water and sanitation.
Working through a local partner, Backward Society for Education (Base), WaterAid has begun improving Wash in health facilities in the province with funding from Giorgio Armani’s Acqua for life campaign, focusing on birthing centres in an attempt to reduce newborn deaths.
The 2016 demographic and health survey shows that in Nepal 5% of under-fives get diarrhoeal diseases.
Given that only half of healthcare facilities in the country have areas where disinfection can take place – or even for staff and patients to wash their hands – it’s not surprising that it will take approximately $6bn more funding for Nepal to meet WASH targets contained in the sustainable development goals.
More women are giving birth in health centres. In Nepal they are incentivised to do so with a 1,000 rupee (£11.35) benefit, but health gains are at risk if women deliver in unsanitary conditions.
The next WaterAid project will take place at Bhimmapur health post, a catchment area of 10,000 people a few miles from the Indian border. Yujin Kushmi, who runs the post, his shirt stained with iodine after delivering a baby girl of 2.22kg earlier in the day, is monitoring the mother, Mina Tharu, for haemorrhage.
The 30-year-old, who previously had a stillbirth, went into labour around 4am and had to walk for 30 minutes to get here. Ideally, Kushmi would have referred her to a better equipped centre, but she was fully dilated on arrival and couldn’t afford the journey in any case. Everyone is eligible for a transport grant, but payments come months later. The mother of four says she’s not planning on more children.
Base will start work here shortly to provide clean water. The existing supply is mud coloured, and there’s a problem with arsenic contamination. This and the toilets are patients’ main complaints. The area is prone to flooding and Kushmi is embarrassed about only having one handwashing point. He urgently wants change.
In the past two years, he and a colleague, Bishnu Prasad Tharu, have opened a birthing centre, a huge step forward for local women. They anticipate 270 deliveries a year.
There’s enough soap, but they lack disinfectants and surgical gloves. There can also be shortages of instruments and gauze.
“Now, hygiene is the first priority,” he says. “There are so many children sick with diarrhoea, pneumonia and respiratory infections.” Cases of infection have gone up to the extent that he and the four other medical staff have questioned the hygiene here, as well as the challenging conditions at some patients’ homes. Adults, too, come in with gastritis and diarrhoea.
To prevent infection, Kushmi routinely prescribes a course of antibiotics to all mothers after birth, alongside iron and folic acid. He also gives antibiotics to newborns with a fever or more than 10 blisters, indicating sepsis. There have been 15 cases so far this year.
Kritima Agri is now a month old and has doubled her birth weight. Her parents say they can finally relax and enjoy being parents. Her mother would like her to be a doctor: “That way she will help everyone else through her hard work, just as she has been helped,” she says.
First, she must complete her course of antibiotics.