Despite a transformation in health services, Nepal continues to endure health system challenges at all levels. Several contributing factors include lack of transportation, poor quality roads, unavailability of quality healthcare facilities, low health literacy, and lack of communication which all play significant roles in the delay of diagnosis and treatment. This study aims to investigate the unexpected death of a nursing mother traveling on the bus in the remote hilly region of Nepal to highlight deficits in the healthcare system and the possibility this death could have been prevented. The starting point of the investigation was done through secondary sources of information such as online media. Also, an in-depth face-to-face interview was conducted with the victim’s husband. The main finding of this study showed the woman who died on the bus while nursing her child highlighted a serious health system challenge. The exact cause of the mother’s death was unrecognized. Early case identification and proper management at the local level were deemed to be a context-specific corrective measure to prevent death. This paper aims to demonstrate the unexpected and untimely death of a nursing mother, due to multiple factors including gaping deficits in the healthcare system across Nepal.

• Child

• Death

• Health Care

• Mothers

• Travel

• Nepa

Dhital SR, Dhital MK, Dhital GK, Oli PK, Bhakta Bahadur KC (2024) Untimely Death of a Nursing Mother during Bus Travel in a Remote Area of Nepal: A Case Study. Ann Community Med Pract 9(1): 1056.

Health care services remain a challenge for the remote population in Nepal [1-3]. Nepal’s constitution 2015 (2072 BS) endorsed that basic health care services are a human right which is in line with the United Nations’ declaration [4]. However, there is a gap between rural and urban accessibility of health care services [5]. The disparity in the doctor-nurse ratio is evident where there is less than 1 medical doctor or nurse per 1000 population while the World Health Organization recommends a ratio of 2.6 per 1000 population [6]. The delay in the assessment of health presentations and inadequate disease prevention or health promotion programs remains a significant challenge in improving quality and timely health services [7,8]. Due to barriers and deficits in health service delivery, people do not receive timely or quality health care treatment at an affordable cost. In addition to this, many people have poor health literacy related to the knowledge and need for early detection, early treatment, and timely check-ups, compounded by difficulties with transport and geography [9]. There are some case studies [10-12] available, but such an emotional and unexpected case study such as this one has not yet been reported in Nepal. Therefore, this paper aims to demonstrate the unexpected and untimely death of a nursing mother, due to multiple factors including gaping deficits in the healthcare system across Nepal.

This study was conducted using a secondary source of information such as national and local newspaper reports available online. Online messages published in the Swasthya Khabar Patrika, Health Today, Kantipur Nepal, and Gorkhapatra Daily were carefully assessed. Further, the victim’s husband was asked to verify the information and make this study reliable about the situation and the mother’s previous health condition. The telephone contact was made with the victim’s husband to fix the time and date for the visit. As per his feasible time, one of the authors visited him and asked about this real case happened. The narrative description was completed after receiving details information.

Case Reports

In August 2021, a 28-year-old scheduled caste woman from a poor socio-economic background in Aathbishkot Municipality-9, hilly district, Rukum of Nepal needed to make a journey by public bus for health care reasons. Rukum is one of the geographically and socio-economically remote districts, 600 km from the capital city, Kathmandu, Nepal. This region has an inadequate health care service with poor access to the necessary resources. This woman has a small family with 32-month-old son and her husband. She lived in a rural village while her husband lived in Nepalgunj where he was employed in the construction industry. With some health concerns, the woman accessed the district hospital at Rukum and the local pharmacy for advice and was given some medicine and obtained an ultrasound.

On the 19th of August 2021, she decided to go to Nepalgunj to be with her husband and to seek further health treatment. Rukum only can provide the most basic of healthcare and there is concern the mostly provisional diagnosis in this rural area might result in the wrong treatment and potentially lead to severe health consequences.

Figure 1: A mother died on a bus in remote Nepal. Setopati online news.

During this initial treatment in her local health facility, she spent 400,000 (approximately AUD 5,000) after receiving some loans and borrowing from her parents. However, she did not feel better and decided to make the journey to Nepalgunj, starting her journey with her child from Radi, Rukum at 5.32 PM on the same day. She managed all her household work as early as possible before departing to Nepalgunj and had asked her neighbor to take care of their home until her return from the treatment. The family did not have anyone who could safe-guard the home in her absence.

The most common way to travel to Nepalgunj is by public bus, mostly on very narrow gravel roads, which are often treacherous. She started her journey at night with her child. Her husband was worried about her health condition as he was aware her blood pressure was unstable and there was no local treatment available to her be-fore her journey. During her journey, her husband frequently communicated by phone. The bus stopped in Chheda for food and extra passengers, and she took the opportunity to have some dinner. During this time, she talked to her husband on the phone and until this time she was fine. They were in regular phone contact until reaching Dharapani but after here the phone communication stopped.

It was late at night and the bus was constantly moving along the rough roads. After some consideration, her husband concluded he would meet his wife the following morning, so he comfortably retired to bed for the night. There was a 27-year old man seated near the woman on the bus. She was routinely taking care of her child and herself on the bus but suddenly felt nauseated and vomited as the bus continued on its way. All the other passengers were sleeping and no one knew about her health condition. In the meanwhile, she asked the 27-yearold man if she could move to a seat toward the front and he obliged by exchanging seats. Normally the rear seats are very uncomfortable compared to the front seats while travelling in the hill region. Before reaching Botechour Surkhet she had vomited 2-3 times and her health condition was poor.

At midnight all the passengers were sleeping, the driver was playing music and the journey continued. The reason bus drivers play songs is intending to stay awake and maintain concentration on these journeys. When the bus reached “Harya Hills” Bardiya Rashtriya Nikunj and over the Chhinchu (about 15 km), suddenly her child cried, heard by the 27-year-old male who then provided her with a polythene bag for her vomiting. The child slipped under the seat and the mother was witnessed to lose consciousness on the seat of the bus. Other passengers including the 27-year-old male tried to wake her but she did not respond.

They assumed all her vital signs had ceased, and they were all shocked and saddened by what was happening. There were no health care services and certainly no access to emergency services. Some passengers suggested taking her to Babai Bazar which is located on the way to Koholpur and after crossing the forest of “Harya Hill”. Unfortunately, there were no health services open at that time of night and the final option was to reach Koholpur. Everyone on board the bus did not know if she was alive or dead and did not know what they could do for her. The child was crying continuously for his mother so the passengers did what they could to console him.

The next morning, the bus reached Koholpur bus park, and her husband was waiting to receive her and their small child. The child was overjoyed to see his father, but worryingly the woman was still unconscious. The husband called for a nurse immediately. The nurse assessed her vital signs and concluded the woman had died. As expected, the husband was distraught but somehow, still hopeful, he frantically requested the driver take them to Nepalgunj hospital as fast as possible. The hospital admits her to the Intensive Care Unit (ICU) for assessment. With all assessments by various persons up to this point it is only with a medical officer’s confirmation can the hospital officially pronounced her as dead. Heartbreaking for the husband and thankfully for him the woman’s brother was working in the Nepal Army in Nepalgunj, so he was able to come to the hospital to provide some support.

In retrospect, it seems the woman must have died on the bus at “Harya Hill” which was devastating for all concerned. We can speculate it was a cardiac event leading on from the untreated high blood pressure in her hometown.

This paper aims to demonstrate the unexpected and untimely death of a nursing mother, due to multiple factors including gaping deficits in the healthcare system across Nepal. This study in this format is perhaps unlikely to be found in the literature. However, there might be many women and men who have died due to the absence of a quality healthcare service in their local settings in Nepal. After reading this story, it is evident there are gaps in the health care service in Nepal, including health education around first aid for everyday citizens, access to emergency services in remote areas, and upgrading of local health services in regional areas. The first concern is this young woman has left her child without a mother, but secondly, why was it necessary for her to travel 300km to Nepalgunj for treatment? Why could she not be treated in her hometown, why were there not emergency services available to her along the bus route and why do those in rural areas seek health care at a larger hospital at critical moments?

Source: https://www.setopati.com/social/246733 [13].

To address these questions, it must be explained that Nepal has a three-tier health care system “federal, provincial, and local level”. Different health care systems have different roles (for example public health services, clinical services, and specialist services) aimed to provide universal health coverage. This framework offers a starting point for rethinking the purpose and organization of the health system and an opportunity to introduce the quality-of-care agenda into policy discourse [14]. Although Nepal’s 2015 constitution guaranteed basic health care as a fundamental right, access to quality care remains a privilege at all levels [4]. There is a cheap slogan in Nepal about health care services that claims all people receive health services at all levels. However, there re-mains an unequal distribution of quality services and it is, in part due to this inequity that this woman lost her life. Rukum district belongs to a remote area where quality health care is minimal. In this case, the woman went to Nepalgunj because there were no advanced healthcare services in the Rukum district [15]. Inadequate supply of skilled medical doctors, types of equipment, and facilities were obstacles for her to receive adequate health care from the local services. Private medical clinics tend to provide all services without adequately investigated diagnosis and with the requirement for often unregulated payment. This has the potential for undiagnosed serious conditions, worsening health status, and even delays in diagnosis.

Compounding this issue is, like many districts in Nepal, the Rukum district has atrocious road conditions and geographical difficulties in traveling to advanced health facilities, such as in this case to Nepalgunj. In most areas, ambulance services are absent or unavailable for various reasons. The local municipality may or may not have an emergency plan for their district. In some cases, there is a lack of awareness of the need to seek medical help but there also remains a gap in coordination of health care and significant barriers around family poverty and sup-port.

Finally, women’s power in decision-making for any issue remains low in Nepal [16]. Most women depend on husbands, grandmothers, and grandfathers in rural areas to make decisions for them. If the woman in this study had independent decision making power, then she may have been able to seek a medical check-up in the early stages. However, the barriers around education, high workload at home, poverty, and discrimination make this nearly impossible for many.

This study has highlighted significant gaps and deficits in the delivery of health care in Nepal. The challenge of service delivery must be addressed. The policymakers must investigate and understand the balance needed be-tween health promotion, disease prevention, and curative services at all levels. The referral system must be strengthened, to enable delivery of appropriate care at the right time. With this discussion, this study has provided detailed information about the untimely death of a young mother nursing her baby while traveling late at night on a public bus.

This study hopes to sensitize policymakers to strengthen local-level health systems and treatment with a robust referral system. However, it must be acknowledged this study cannot be generalized to all spheres and settings. There might be reporting bias related to this case that we are not privy to, such as scientific information related to her death or distorted information gathered from the husband due to the emotion of the ordeal. Finally, this study is purely meant to be an illustration of the possible implications stemming from a flawed and inequitable health system. It is difficult to summarize this case into the general proposition of theories. A multi-level healthcare service-providing approach is recommended in line with Nepal’s geopolitical reforms for timely quality healthcare services [17].

This study demonstrated an amalgamation of events and circumstances that led to the untimely death of a young mother on a bus in a remote area of Nepal. If forensically examined there is likely to be causal factors such as lack of communication and reporting on her pre-existing health condition in time. We must also examine the low level of quality health care and the underestimation of diseases in regional and remote areas of Nepal. Finally, physical factors such as dangerous road conditions, vehicle speeds, and the contributing factor of motion sickness may have also contributed to the demise of the woman’s health. Equal distribution and access for all to advanced health care is key in this study. All regions must be equipped with a hospital/ health service capable of advanced technology within a reachable and affordable distance. If this is not possible the mechanisms for referrals and safe/timely transportation to tertiary-level care are paramount. Each rural and urban municipality must take responsibility for citizens’ health conditions with primary and secondary levels of prevention and referral mechanisms for the tertiary level of prevention.

We thank Dal Bahadur Batala (husband of the case) who provided real information about the case and also gave consent for the publication. We also acknowledge Vickie Owens for reviewing the language of this article.

SRD: conceptualization, methodology, writing – original draft, review & editing

MKD: methodology, review & editing

GKD: project administration, review & editing

PKO: investigation, visualization, writing – review & editing

BBKC: review & editing.

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