- Background and Historical Context
- Core Challenges
- Possible Interventions
- Additional Readings and Resources
A country where 81% of births occur at home, Nepal lacks standard practices of hospital deliveries. This deficit is due to factors such as the perceived lack of necessity of health providers in delivery and the lack of transportation to and from medical facilities. However, the emergence of maternal and child health workers and skilled birth attendants has proven successful in educating women about birthing practices. Structural and social barriers to health services, food, and housing following natural disasters disproportionately affect women and children in comparison to men. In Nepal, there are several core challenges to addressing maternal and child health, some of which include role of the husband, the issue of gender-based violence affecting women, and the three delays that arise when seeking medical care. Possible interventions that would benefit maternal and child health include improving community based health services by providing more developed training programs for skilled birth attendants, in addition to increasing male engagement in the mother’s health. The earthquake is poised to create setbacks for Nepal unless a concerted effort between the Nepali government and international aid efforts ensures that maternal and child health is not overlooked by emergency response agencies. International organizations like the United Nations Population fund (UNFPA), OneHeart, and UNICEF are working together to bring women and children safe spaces and health resources.
Cultural Understanding of Birth and Pregnancy
It was not until the 1980s that maternal mortality was added to the international health agenda as a major public health issue (1). Each year, around 358,000 women die because of complications during pregnancy or childbirth (1). Factors that contribute to Nepal’s high maternal death rate and reproductive morbidity include lack of adequate healthcare facilities and trained health personnel, and an overall delay in reaching care (12). The majority of these deaths occur in developing countries like Nepal, where more than 80% of births occur at home (2). In Nepal pregnancy is considered to be natural, therefore regular check ups and seeking health providers are believed to be unnecessary. Women are most at risk of health hazards because of early marriages, increased number of pregnancies, and unmedicalized birth. Due to Nepal’s patrilineal kinship system, pregnancy and childcare is a woman’s concern.
The Nepali health care system is overwhelmed and 18,000 babies and mothers’ lives are at risk (3). 70% to 90% of Nepal’s birthing centers across the 14 most affected districts were damaged or completely destroyed (20). According to statistics from the United Nations Populations Fund (UNFPA), the earthquake in Nepal has impacted 1.4 million women of reproductive age (4). There are an estimated 93,000 women who are pregnant and 10,300 women are expected to deliver each month since the earthquake (20). Over 1500 women may experience complications in birth that would require C-sections. Please note that the statistics compiled here, following a natural disaster come from several and often conflicting sources. It is important to be cognizant of any gaps or inherent biases found in the data.
Millennium Development Goals
The damage caused by the earthquake will also impact how the country of Nepal will be able to meet the Millennium Development Goals regarding reducing child and maternal mortality.In September 2000, world leaders came together at United Nations Headquarters in New York to adopt the United Nations Millennium Declaration, which developed a series of targets to reach by 2015 to reduce extreme poverty. The targets are known as the Millennium Development Goals (5). By 2015, Target 5a aims to reduce by three quarters, between 1990 and 2015, the maternal mortality ratio and target 5b aims to achieve universal access to reproductive health. As of 2010, the number of women dying in childbirth worldwide fell by 47%, however, the United Nations made an announcement in 2012 that stated, “…progress is still slow. Reductions in adolescent childbearing and expansion of contraceptive use have continued, but at a slower pace since 2000 than the decade before” (6).
Maternal and child health workers
In developing countries, particularly in rural areas, the standard practice of hospital deliveries is unattainable. One way to address this is through the implementation of a referral system for deliveries (8). Low-risk births are handled at the local level by maternal and child health workers (MCHW) and high-risk births are referred to a district or regional hospital (9). The MCHWs are local women aged 18-35 who have completed a 15-week course in maternal and child health and a further six-week ‘refresher’ course in midwifery skills (2). Not everyone benefits equally due to the lack of transportation between rural areas and the nearest hospital. The percentage of deliveries assisted by skilled birth attendants is 10.7% for poor rural people and 81.5% for the richest quintile (10). Although progress may be slow, Nepal has seen an 80% decline in maternal mortality between 1991 and 2011. The use of maternal health services has improved since 1996, with increases in the number of both antenatal care (ANC) visits and deliveries attended by skilled birth attendants (SBA) (6).
“…vulnerable newborns and pregnant mothers urgently need support as the risks of premature birth, miscarriage and complications rise amid the stress and confusion caused by the earthquakes. We expect around 90 women a day to need a caesarean section in the affected parts of Nepal and, at present, the systems cannot cope.” –Tomoo Hozumi, UNICEF Representative to Nepal
Structural and social barriers to health services, food, and housing following natural disasters disproportionally affect women and girls compared to men and boys (11). In particular, pregnant women are in need of prenatal care, a safe birthing place, and medical attention in the event of complications. New mothers are in need of postpartum care and nutrition and newborn children are especially at risk following birth.
Before the earthquake, Nepal’s maternal mortality rate has been a major health issue; the main cause is due to delivery related causes such as hemorrhaging (Figure 1). This issue has an even larger impact for Nepali women because traditionally, most births in Nepal occur at home. Without skilled birth attendants, birthing complications have an even greater risk of mortality for both mother and child. The earthquake is poised to create setbacks for Nepal unless a concerted effort between the Nepali government and international aid efforts can take place.
Following the earthquake, women and children in Nepal are at a greater risk for violence and sexual abuse. Pregnant mothers and vulnerable newborns are in desperate need of resources. According to UNICEF representative of Nepal, Tomoo Hozumi, an average of 90 women a day need a C-section in the most affected parts of the country (20). Moreover, thousands of children have been displaced and left without a family and now run the risk of becoming victim to human trafficking. An intervention model must be developed for maternal and child health in Nepal that focuses on addressing core challenges such as gender roles, violence, and delay seeking care. In a global health perspective, the skills utilized to develop these interventions can be applied to other countries affected by natural disasters.
- Gender Based Violence (GBV)
- Following natural disasters, there is increased violence against the most vulnerable groups of people-women and children
- In Nepal, GBV has been an issue long before the earthquake
- Women did not speak about violence issues as it is considered a taboo
- There were also few services originally intended for women and children affected by the earthquake that must be addressed.
- Three Delays to seeking care
- The ‘three delays’ include delay in taking the decision to seek medical assistance, delay in accessing appropriate care, and delay in receiving care at health centers.
- A number of studies in Nepal have reported that the delay in seeking help is due to cultural beliefs, problems of finance, transport, and contemplating the decision to seek medical assistance. (1)
- Many Nepali people, especially in rural areas, believe that the complication is created by an evil eye and thus seek help from traditional healers (Shamans) before seeking medical help. (1)
- Following the earthquake, the delay to care has been exacerbated due to an overwhelmed health infrastructure system. Acute injuries can often take precedent over maternal and child health.
- Role of Husband
- Patrilineal kin groups form the nucleus of households, and determine inheritance patterns.
- A man permanently belongs to the kinship group of his father, while a woman changes membership from her natal kin group to the group of her husband at the time of marriage.
- There are many barriers to paternal involvement such as a lack of knowledge, pressures of job responsibilities that keep them away from home, and a social stigma that surrounds men who are more involved in their wives’ and children’s lives.
- Paternal involvement is often overlooked by health programs in developing countries, and most health programs often only direct advice and interventions towards mothers.
- Improving Community Based Health Services
- One possible intervention most directly benefiting maternal and child health would be to improve the available community based health services available and to provide more developed training programs for skilled birth attendants.
- Community health workers can incorporate pamphlets to educate people on maternal and child health as seen in figures 1, 3, and 4.
- The brochures can address core challenges such as knowing when to seek antenatal checkups and help in case of birthing complications.
- The skilled birth attendants could focus on paternal engagement in the mother’s health through couple-friendly reproductive health services.
International aid and birthing tents and prenatal care
- Due to the earthquakes, homes are no longer safe places to give birth.
- Birthing tents would give women a safer place to give birth with some semblance of available medical technology. As seen in the image below.
- “The intrapartum period is considered to be a key site for intervention in maternal mortality in Nepal”; these birthing tents would be crucial in helping save lives. (8)
- International aid could also provide educational workshops for expecting mothers and provide basic hygienic necessities such as sanitary pads and clean clothes.
- However, it is also important to keep in mind that “individual (patient’s’) cultural beliefs or practices cannot be disregarded in order to provide information and education” so it is important to take local cultural practices into consideration when foreign organizations come into disaster-struck areas, such as Nepal. (18)
OneHeart World Wide
OneHeart World Wide, although committed to a biomedical model, is an organization that utilizes local community workers to develop a culturally appropriate “Network of Safety”, which aims to decrease maternal and neonatal mortality and morbidity in rural Nepal. OneHeart specifically addresses the problem of rural access to non-rural hospitals. There are several regional hospitals staffed with highly trained medical professionals, but many Nepali women live hours or even days from the nearest hospital. OneHeart concentrates on raising awareness, teaching good practices, and distributing essential supplies to ensure the survival of mothers and their children during delivery as well as the months to follow. (13)
“I truly appreciate that you are thinking of our unique needs. Food is important, of course, but proper hygiene and decent clothes make me feel like a normal person again” –
Sharmila Thapa, mother of a six-month-old baby
The United Nations population fund (UNFPA) has been working with the government, and community based organizations to ensure that reproductive health is not overlooked by emergency response agencies. In partnership with the Nepal Ministry of Health, UNFPA has launched the “Dignity First” campaign. This form of health intervention includes dignity kits that have clean clothes, sanitary pads, and other hygiene necessities. The campaign’s mission is to “help restore a sense of dignity and poise” (14). UNFPA is also funding Female Friendly Spaces (FFS) in the regions affected by the Earthquake. Women and children can come to these safe spaces in refugee camps, report violence, seek services and workshops. FFS has helped over 6,000 women and children in 13 of the 14 most affected districts. Overall, FFS aspires to make women and children feel safe.
UNICEF has been working with partner organizations to distribute aid and set up emergency medical and maternity tents in affected areas, which offer care to displaced pregnant women with complications. They have established mobile clinics to deliver emergency primary healthcare for vulnerable mothers and children in areas where health facilities have been damaged or destroyed. They have also delivered scores of clean delivery kits to Sindhupalchowk and Gorkha districts, and hundreds of blankets to Lalitpur, Ramechhap, Dhading, Sindhupalchowk and Makwanpur districts, and the Maternity Hospital in Kathmandu. UNICEF is also providing iron and folic acid supplements for pregnant and new mothers and distributing hundreds of sets of baby clothes in Sindhupalchok and Gorkha districts. (20)
1. This article by Dhakhal is a study regarding the importance of antenatal care among women in rural Nepal.
2. ReliefWeb is published by the United Nations Office for the Coordination of Humanitarian Affairs and provides international updates of Nepal’s post-earthquake progress.
3. This article by Shrestra addresses maternal mortality in Nepal, which is very relevant to our case’s topic.
1) What issues arise when international organizations solely implement a biomedical model in non western countries?
2) How would factoring in Nepal’s diverse ethnic groups change the way medical professionals and global health workers provide maternal and child health interventions?
3) How can one address paternal involvement without interfering with the local cultural patrilineal context?
On April 25th 2015, news stations around the world filled our screens with images of ruined homes and displaced people following the first earthquake in Nepal. International aid, NGOs and volunteer groups poured into the country to provide relief. As time passes, news cycles transition to the next pressing issue and temporary relief groups return home, yet hundreds of Nepali-based organizations continue to work to empower both themselves and others impacted by the earthquake. Resilience comes from different sources and takes different forms. Yet, the people of Nepal continue to move forward, each day at a time.
- Shrestha, Roman. “Maternal Morality in Nepal: Addressing the Issue.” Student Pulse. Student Pulse, LLC, 2012. Web. 2 Aug. 2015. <http://www.studentpulse.com/articles/708/4/maternal-mortality-in-nepal-addressing-the-issue>.
- Dhakal, Sulochana, et al. “Antenatal Care among Women in Rural Nepal: A Community-based Study .” Online Journal of Rural Nursing and Health Care 11.2 (2011): 12. binghamton.edu. Web. 4 Aug. 2015. <http://rnojournal.binghamton.edu/index.php/RNO/article/view/20>.
- “Nepal: Earthquake 2015 Situation Report No. 20 (as of 3 June 2015).” ReliefWeb. United Nations Office for the Coordination of of Humanitarian Affairs, 3 June 2015. Web. 3 Aug. 2015. <http://reliefweb.int/report/nepal/nepal-earthquake-2015-situation-report-no20-3-june-2015>.
- “Earthquake in Nepal.” UNFPA United Nations Population Fund. UNFPA, n.d. Web. 1 Aug. 2015. <http://www.unfpa.org/emergencies/earthquake-nepal>.
- “UN Millennium Project.” Millennium Project. UN Secretary-General, 2006. Web. 6 Aug. 2015. <http://www.unmillenniumproject.org/index.htm>.
- “Achieving MDG 5: the facts .” Maternity Worldwide. Maternity Worldwide, n.d. Web. 3 Aug. 2015. <http://www.maternityworldwide.org/the-issues/achieving-mdg-5-the-facts/>.
- “Nepal Earthquakes: Babies and Maternity Services.” Online posting. UNICEF WeShare. UNICEF, 2015. Web. 10 Aug. 2015. <http://weshare.unicef.org/C.aspx?VP3=SearchResult&LBID=2AM4EB387HF&IT=Thumb_Grid_L_Details_NoToolTip>.
- Brunson, Jan. “Confronting maternal mortality, controlling birth in Nepal: the gendered politics of receiving biomedical care at birth.” PubMed (2010): n. pag. Web. 8 Aug. 2015. http://www.researchgate.net/publication/45659618_Confronting_maternal_mortality_controlling_birth_in_Nepal_The_gendered_politics_of_receiving_biomedical_care_at_birth
- Carlough, Martha, and Maureen McCall. “Skilled Birth Attendance: What does it mean and how can it be measured?” PubMed (2005): n.pag. Web. 8 Aug. 2015. http://www.researchgate.net/publication/7889533_Skilled_birth_attendance_What_does_it_mean_and_how_can_it_be_measured_A_clinical_skills_assessment_of_maternal_and_child_health_workers_in_Nepal
- Nepal Helps New Moms Gain Access to Care. Dir. World Bank. 20 Sept. 2013. YouTube. Web. 4 Aug. 2015. <https://www.youtube.com/watch?v=oSeVPs-TVfM&feature=youtu.be>.
- “Gender Responsive Disaster Risk Reduction.” ReliefWeb (2014): n.pag. Web. 5 Aug 2015. <http://reliefweb.int/report/world/gender-responsive-disaster-risk-reduction>.
- Malla DS, Giri K, Karki C, Chaudhary P. Achieving Millennium Development Goals 4 and 5 in Nepal. BJOG 2011;118 (Suppl 2): 60-68 http://onlinelibrary.wiley.com/doi/10.1111/j.1471-0528.2011.03113.x/pdf
- “Nepal.” One Heart World-Wide. One Heart World-Wide, n.d. Web. 10 Aug. 2015. <http://www.oneheartworld-wide.org/index.php/programs/nepal>.
- UNFPA, Asia and Pacific Regional Office. “Dignity Kit – Nepal Earthquake.” United Nations Population Fund. United Nations Population Fund, May 2015. Web. 6 Aug. 2015. <http://www.unfpa.org/resources/dignity-kit-nepal-earthquake>.
- Restoring the dignity of women and girls. Dir. UNFPA Nepal. United Nations Population Fund, 8 July 2015. YouTube. Web. 10 Aug. 2015. <https://www.youtube.com/watch?v=8_SDWlPBJ6E>.
- “NZ sending USAR team to Nepal.” Radio New Zealand News (2015): n.pg. Web. 27 April 2015. <http://www.radionz.co.nz/news/national/272200/nz-sending-usar-team-to-nepal>
- LoLordo, Ann. “In aftermath of Nepal earthquake, Jhpiego doctor and family host 1,000 house guests.” John Hopkins University Hub. 4 May 2015. Web. 23 August 2015. <http://hub.jhu.edu/2015/05/04/nepal-earthquake-jhpiegpo-doctor#>
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- “Nepal Earthquakes: 12 babies born every hour without basic healthcare in worst hit areas – UNICEF.” Online posting. UNICEF Press centre. UNICEF. 15 May 2015. Web. 10 Aug 2015 <http://www.unicef.org/media/media_81896.html>
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