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The Pragmatist

By Amanda Kolson Hurley
Saving women’s lives in remote and rural areas requires a mix of bravery, will, and smarts. Kusum Thapa helped revolutionize maternal health in her home country of Nepal. Now she’s taking on the world.

In 1995, Kusum Thapa, a 35-year-old doctor, was new to Koshi Zonal Hospital in eastern Nepal when she entered an exam room to find a female patient pale as a sheet, with blood pooling around her. The woman’s husband and two children stood vigil at her side. The husband held a newborn baby.

The woman lived in a remote village in the mountains and had started bleeding heavily after delivering her child at home. Her mother-in-law sought help in the nearby village, and the woman was carried on a handmade stretcher, three hours by foot, to a health clinic. The staff in the clinic did not have the skills to treat her, however, so the woman was lifted back on the stretcher and carried another four hours by foot to the nearest hospital. There, Thapa’s team tried, but failed, to save her. She had already lost too much blood.

“This is the story of women in Nepal,” Thapa says.

A rectangle of land 500 miles long, Nepal consists of plains, but also rugged mountains. The Himalayas stretch across the country, with Mount Everest and several of the world’s highest peaks clustered in the northeast. “Our mountains are our pride but a real contributor to our maternal mortality,” Thapa says. Like the woman brought in on the stretcher, many Nepali women must walk or be carried for hours to reach a health facility capable of treating them.

Nepal is not unique. Around the world, more than 800 women die each day from causes related to pregnancy and childbirth. Ninety-nine percent of them live in developing countries, and within those countries, poor women in rural areas bear the greatest risk. Thapa has spent the past three and a half decades fighting for women’s lives. She has treated vulnerable patients amid civil war, in inaccessible terrain, and in the rubble of an earthquake. She has worked as both a physician and an architect of health policy at the national and international levels. Her years working in the field, and advocating for better patient care and modern methods of treatment, have given her a keen understanding of policy reforms that don’t just look good on paper but work in the real-life circumstances found in the far reaches of developing countries.

Around the world, more than 800 women die each day from causes related to pregnancy and childbirth. Ninety-nine percent of them live in developing countries, and within those countries, poor women in rural areas bear the greatest risk.

Today, Thapa is the senior maternal health adviser in the maternal and newborn health program at Jhpiego (pronounced “jeh-PIE-go”). The nonprofit organization, which is affiliated with Johns Hopkins, is devoted to women’s health, and for over 40 years, it has worked to prevent the needless deaths of women and their families in more than 155 countries. Thapa has traded the rural areas of Nepal, her home country, to live in Washington, D.C. Still, she spends about half her time in countries like Afghanistan, Laos, Liberia, and Myanmar, sharing the latest in medical findings, and teaching doctors and nurses to provide better care for women and babies. What propels her is an urge to help, she says, one that was instilled after learning of her mother’s own near-death experience during a pregnancy. “I was lucky, in my life,” Thapa says. “I’ve always had these opportunities of helping people.”

Thapa’s calling to help women has not always been easy—or safe. The work has put her own life at risk. But more than luck, it has been Thapa’s desire to challenge conventions in both the classrooms where she was trained and the clinics where she has worked, in order to bring modern medical care to the far reaches of the planet.

Kusum Thapa was born in 1960 in Kathmandu, Nepal’s capital. She was one of four, three girls and a boy, in an upper-middle-class family. Her father was the superintendent of police for the government of Nepal; her mother was a homemaker who married at 18 and gave up her studies but was determined for her children to pursue theirs.

“During my time, girls’ education [in Nepal] was not very important,” Thapa says over tea in her small, functional Washington office of Jhpiego. A petite woman in her 50s, Thapa has a nimbus of curly hair and large eyes made bigger by dark liner around the rims. “But my parents made sure that we were all educated.”

Her wish to become a doctor, and specifically an OB-GYN, was rooted in her family history. Growing up, she repeatedly heard the story of her mother’s ordeal during one of her pregnancies, when Thapa was a toddler. Her mother had had preeclampsia—a pregnancy complication characterized by high blood pressure—which progressed to eclampsia, a life-threatening condition.

Thapa’s mother fell into convulsions, lost consciousness, and was taken to a hospital, where a missionary doctor—a woman—treated her. She recovered. But she lost the baby. ‘“I really felt that if it wasn’t for this doctor, this female doctor in this hospital, and if it wasn’t for the fact that we were in Kathmandu, we would have lost my mother,” Thapa says. “This was something which I felt I should also work at, so that nobody’s mother ever dies again.”

There were no medical schools in Nepal at the time, so Thapa went through the competitive process of applying to college in India. She was the only one of her school friends to get a place. At the age of 18, she left for Kolkata (then Calcutta) Medical College, the oldest medical school in South Asia, established in 1835.

There were about 150 students in her class, a third of them women. This was a change from previous years, Thapa says, when women made up a much smaller percentage of the student body. When the principal of the college gave his opening address to incoming students, “he said that he was very disappointed that year because there were more girls enrolled,” Thapa remembers. “He said that lady doctors are neither ladies nor doctors.” The young men clapped and laughed, and the female students “were just so unhappy inside.”

Thapa smiles: “Then we proved him wrong.”

In Kolkata, when she wasn’t studying, she learned the local language, Bengali. On weekends, she and her friends would take the tram to Mother Teresa’s orphanage, where they helped the nuns bathe and feed malnourished children.

After finishing medical school, she returned to Kathmandu and married Iswar Singh Thapa, a young Nepali engineer. She continued her training, working in hospitals in Kathmandu and Pokhara, Nepal’s second largest city. In 1993, she left for the U.K. and the Princess of Wales Hospital in Bridgend, a town near Cardiff, the capital of Wales.

Thapa’s husband stayed in Nepal and looked after their young son while she worked. “I have a very supportive husband,” she says. “If it wasn’t for him, I wouldn’t be doing so many things which I am doing at the moment.”

In Wales, Thapa thrived. She was on a career track that led to the position of registrar, a respected and well-paid specialist role within Britain’s National Health Service. But something nagged at her: Thapa’s patients were already in good hands. Was the U.K. really the best place to put her skills to work?

She returned to Kathmandu and taught medical students there, but the problem was the same. The capital had doctors and good hospitals. The need was greater elsewhere. Thapa decided to go to “the periphery,” as she calls it. Nepal’s population of 29 million is mostly rural; Kathmandu is the country’s beating heart, the seat of government and a tourist draw, and with 5 million residents, by far the largest population center. Two hundred kilometers to the east lies Biratnagar, an industrial city of 200,000 people. Thapa asked to be posted there. Moving to Biratnagar was a turning point in her life.

In Biratnagar, Thapa and four colleagues were the only OB-GYNs for miles around. The place was a backwater not only in the eyes of officials in Kathmandu but also in the opinion of some of the global agencies that fund health care in developing countries.

Jhpiego, though, was working in Nepal. Staff focus on practical steps that health providers without many resources can take, rather than costly or high-tech interventions. “Training the trainers” is a key strategy: The organization has created a global network of doctors, nurses, and midwives who train other health workers. They often use anatomic models to minimize the risk to human patients, and these days, trainings are as likely to be delivered via computer as in person.

In 2001, Jhpiego invited Thapa to become a regional “champion” for maternal and newborn health. The organization was recruiting midcareer physicians and nurses to teach them the latest medical research and train them in new procedures, which they could disseminate in their countries.

The U.S. Agency for International Development, which funded the program, initially balked at bringing Thapa on, according to Harshad Sanghvi, the chief medical officer of Jhpiego. USAID officials feared that she would not be able to put into practice what she learned because she worked in a hospital with so little outside support. The argument that donors didn’t support her was precisely the reason, Sanghvi says, he lobbied to recruit Thapa. Eventually he prevailed, and she joined the program.

The oxytocin shot after delivery was perhaps the single biggest change Thapa introduced as a regional champion. By 2002, Thapa had learned through Jhpiego about a new technique for better managing the third stage of a woman’s labor—the delivery of the placenta. It was a simple technique. Immediately after birth, hospital staff would give the mother a shot of oxytocin, which would make her uterus contract and speed the delivery of the placenta. This would reduce the likelihood of heavy bleeding.

Thapa approached her older male colleagues and suggested they all try the new procedure. At the time, postpartum hemorrhage was the most common cause of maternal death in Nepal.

They said no. They were used to doing things their way and didn’t want to try something new.

Thapa introduced the procedure in her own unit, training her nurses to administer the shot. Sure enough, mothers who received oxytocin experienced fewer bleeding episodes than those who didn’t. She tracked patient outcomes and compiled data to prove the treatment was effective.

But pure medical data, she intuited, would not be enough to bring around the other doctors. How might she overcome their aversion to change? What would convince them that switching to a new approach would be worth the trouble?

“She understood the evidence was not going to be enough. She understood that there were going to be certain triggers that needed to be pulled to get them to change, and she figured out how to do it.”

Thapa looked at the number of times in recent months that she and her colleagues had been called out at night to deal with a case of postpartum hemorrhage. One doctor had been called out 12 times, another eight—but Thapa had been called out only once since starting to give the oxytocin shots. Here was evidence not just that the shot worked but that it could make the doctors’ lives a little less stressful, with fewer 2 a.m. emergencies. She presented these findings. Her colleagues agreed to adopt the new technique.

“She understood the evidence was not going to be enough,” Sanghvi says. “She understood that there were going to be certain triggers that needed to be pulled to get them to change, and she figured out how to do it.”

After the entire OB-GYN team embraced the practice, the hospital had dramatic success at reducing postpartum hemorrhage. Thapa then worked to integrate the technique into the national training of doctors and obstetrical nurses, and now it’s standard in hospital deliveries in Nepal, as it is in the United States.

Many of the changes that Thapa made were simple. Hospital staff in Biratnagar were overstretched and resources very limited. “We did not try to jump [for] the high-hanging fruits,” Thapa says. “We just started with the low-hanging fruits. Let’s do little things first.”

Thapa dedicated lunch breaks to training and made sure that supplies of basic medications were readily available. She posted checklists with instructions on how to perform certain procedures. She even moved furniture around and put up curtains to give patients more privacy. In short order, she made the hospital in Biratnagar a national model of excellence for obstetrics and gynecology.

When Nepalese government officials saw how she had transformed the place, they made it a national skilled birth attendant training center. Thapa understood that training could be an incentive where money was scarce, while improving the standard of care overall. Her nurses learned to do more procedures, such as vacuum-assisted deliveries. As these nurses expanded their skills, they had the chance to train nurses from other parts of the country, who respected their knowledge. So did the doctors, who relied on the nurses more, a change that, in turn, gave the doctors more time to devote to the most challenging and urgent cases.

Thapa also advocated for a larger role for what are called “medical officers” in Nepal, doctors who have completed internships but do not have a specialization or much experience. At her urging, these doctors were allowed to perform cesarean sections after a 10-week intensive training, and now they do so in remote hospitals and clinic settings where OB-GYNs are in short supply.

Over 12 years, Biratnagar became not just Thapa’s professional base but her home, where she lived with her family and their three dogs.

Then, in 2006, she got a phone call.

All the time Thapa had been treating patients in Biratnagar, there had been conflict brewing in the background. In 1996, Maoists had launched a rebellion aimed at overthrowing the country’s monarchy and establishing a communist state. Fighting dragged on for a decade, killing almost 20,000 people, before a peace accord was signed in November 2006. (The monarchy was abolished in 2008, and Nepal became a republic.)

The uprising had not affected Thapa’s work, until she began traveling outside the hospital and into the high mountains. Thapa would visit health camps sponsored by the government, where she and other doctors treated locals without access to regular health care. The man on the other end of the phone that day was one of the rebels. “These people had a reputation for killing, extortion, and kidnapping,” Thapa says.

The man told her he was calling because of a patient she had examined several weeks before. Thapa remembered: A bruised, badly shaken 13-year-old girl had come in showing unmistakable signs of sexual assault. The man on the phone said one of his associates was in custody for the crime and asked Thapa to change her report, reversing the finding. “You know what the consequences will be if you don’t,” he told her. Thapa understood this was a threat.

The next day, back in Biratnagar, she was called to a meeting with the medical superintendent. Six rebels were in the room when she arrived. The superintendent asked her to review the report. She asked to speak to him alone and told him she would not change it. “I would rather die once than die over and over again if I change the report,” Thapa recounted for a live audience in 2016, during a storytelling series called The Moth.

Frightened for herself and her son, then a medical student, she went home. An hour later, she got another phone call: Together, her colleagues and the superintendent had changed the report, overturning her verdict of sexual assault. Her colleagues had complied with the demand out of fear, and with the report altered, the perpetrator could be released.

She resigned the next day.

Thapa went to Kathmandu, giving up the life she had built in Biratnagar: her medical practice, the hospital unit, her home, her dogs. She and her husband moved in with her mother, unsure what to do next.

Sanghvi stresses how much Thapa put on the line in exchange for her integrity. “In a system like Nepal, it is not easy for you to get another job like that,” he says. Doing what she did “destroys your entire life, your career pathway. She made that choice, and it was an incredibly hard choice.”

Jhpiego hired Thapa after Sanghvi learned what had happened. She remained in Kathmandu for several more years, making further advances in maternal health at Paropakar Maternity and Women’s Hospital, and for a time serving as general secretary of the Nepal Society of Obstetricians and Gynaecologists. In that role, she launched a nationwide campaign to reduce deaths from preeclampsia and eclampsia. As deaths in Nepal from postpartum hemorrhage fell through the 1990s and 2000s—thanks to her efforts—preeclampsia/eclampsia became the leading cause of maternal death.

Thapa mobilized dozens of the country’s OB-GYNs and most qualified obstetric nurses to become trainers in hospitals across Nepal, teaching other health care workers how to manage preeclampsia, the condition that had almost killed her own mother.

“It is dramatic how quickly the practice of preventing preeclampsia changed,” Sanghvi says. And the whole project cost $25,000. “If we’d tried to do that from the States, it would have cost us $500,000, $600,000 at the minimum,” Sanghvi says.

He praises Thapa as a problem-solver. But he thinks her chief gift is in motivating people. “One of our challenges in many developing countries is how demotivating the systemic problems are,” he says. “You don’t have people who are well-trained, you don’t necessarily have all the stuff you need, power goes out in the middle of your surgery. Your equipment, half the time, it doesn’t want to work. I think what she has done is remotivate people and say, ‘You know what, it is possible to make a change. That is characteristic of what she does out there. She shows by example.”

Women’s health has improved dramatically in Nepal, thanks in no small part to the changes introduced by Thapa and Jhpiego. The maternal death rate has been cut by three-quarters. More women (close to 45 percent) deliver in health facilities now, encouraged by a government program that gives them a travel allowance and reimburses hospitals and clinics for each baby born.

The decline of postpartum hemorrhage is a major factor, achieved by the oxytocin shot and the distribution of the drug misoprostol to pregnant women who deliver at home. Thapa was instrumental in the adoption of both strategies. Management of eclampsia, improved through the training program she organized, has saved lives, as have calcium supplementation (calcium deficiency is associated with preeclampsia) and other initiatives she supported. Nepal is one of the few countries that reached its United Nations Millennium Development Goals for improving maternal health and reducing child mortality.

In her global role, a big part of which is “training the trainers,” Thapa feels a different kind of satisfaction than when she ran a medical practice. “I feel I can make a difference in the lives of so many women and children. That’s where I see myself.”

Illustration of a Nepalese landscape filled with mountains and greenery
Bud Cook

That means reaching beyond medicine to address a root cause of why women’s health lags in the developing world: their low status in society. In Nepal, for instance, many women marry young and are essentially handed over to their husbands’ families, becoming isolated from their own relatives and friends. Violence against women is common: A Nepalese government survey in 2011 showed that 22 percent of women between the ages of 15 and 49 had experienced physical violence. The leading cause of death in Nepal for women of childbearing age is not any complication of pregnancy or childbirth but, shockingly, suicide.

Thapa remembers one woman she treated, a pregnant mother of three girls. A fortuneteller had told her the next child would be a girl, too, and Devi’s (name changed) husband had pressured her to get an abortion. When Thapa saw Devi, she was four months pregnant and in shock after her husband had stamped on her abdomen, rupturing her uterus. Thapa was able to save her but not her baby.

This was not Devi’s first encounter with health workers during the pregnancy. She had gone to a clinic twice before—once with a black eye, another time with bruises on her back, both of which she explained away as accidents. “If the frontline workers had been really equipped, this woman, the first time she had come to the antenatal clinic with this black eye, they would have started asking her [questions], helping her,” Thapa says.

Thapa wants to make sure other women in Devi’s situation get immediate help. Jhpiego is training health workers in Nepal to be able to identify women affected by domestic violence and, crucially, to protect them. The organization is collaborating with the government, police, lawyers, and other NGOs.

“You need to work at different levels. You need to work with different stakeholders,” Thapa says. “Change is not a magic wand which just happens at once. It takes time and a lot of effort.”

Kusum Thapa
Bud Cook

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