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Solving for the Hardest Cases

Nine months pregnant, twenty-year-old Pabitri was herding goats when she started to feel abdominal pains.

She had been educated by a Possible community health worker about the symptoms and knew that she
needed to go to the hospital. An ultrasound done at a group antenatal care session had demonstrated placenta
previa, a condition that places both her and her newborn at risk. This was her second pregnancy. She had been
convinced to stay close to the hospital, but she had to negotiate subsistence work and care for her two year-old.
When she reached home, her father-in-law rallied community members to carry her 45 minutes down the
road to call a jeep where she could take a one hour ride to Bayalpata Hospital. In transit, however, her labor
progressed and she delivered. The female baby emerged blue. Despite several attempts to revive the child, the
baby appeared dead. They brought Pabitri and the baby back up the hill.

The placenta, however, did not deliver, and the next day, Pabitri bled and ran up a fever. Her community health
worker advised her to go immediately to the hospital to get the placenta removed. Four hours later, the team at
Bayalpata Hospital gave intravenous fluids, stopped the bleeding, gave antibiotics, and removed the placenta.
After two days, not being able to afford the jeep ride back, Pabitri made the four hour trek back home on foot.

Over the last six years in Achham, institutional birth rates in the areas where Possible works have increased from
30% to over 95%, a demonstration that access to facility care and maternal health outcomes are improving.
Pabitri represents that remaining 5% of situations that the team is working hard to overcome. The hospital-based
care was essential in saving Pabitri’s life from bleeding and infection due to the retained placenta, but
she accessed care too late to save her daughter. Given her baby was full term, it is likely that with basic neonatal
resuscitation techniques, she would have survived.

Community health workers need a number of supports – supervision, digital tools, adequate training – but an
under-appreciated one is connection to a well-functioning hospital.

Pabitri’s case sits at the intersection of how economics, access, and quality care are critical to building a
learning health system that solves for the most difficult patients who we serve. It also underscores how one-size
solutions may scale, but leave too many behind.

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