Pregnancy and Childbirth
Attitudes and practices relating to pregnancy and childbirth
in Nepal are influenced by social, cultural and religious
factors. These are often so strong that, at times, they
can seem to be insurmountable barriers to reducing maternal
mortality using rational methods.
In addressing this complex area, the Nepal Safer Motherhood Project (NSMP)
has developed a strong understanding and appreciation of local beliefs and
practices in order to reinforce positive aspects and help to transform others.
Both project staff and partners make continual and concerted efforts to study
local antenatal, childbirth and neonatal practices.
Some of the key issues include:
Marriage and Childbirth
Women in rural Nepal marry at an average age of 16, but
often as young as 13. Newlyweds live with the husband's
parents and about 25% of women give birth to their first
child before they are 18. Family sizes tend to be large
(the total fertility rate was 4.4 in 2001), since children
are seen as divine blessings. There are also strong economic
and social arguments in favour of larger families.
Women are expected to deliver children
without drawing attention to themselves and to bear any obstetric
difficulties without complaint. Over 90% of births take place at
home, with traditional birth attendants (TBAs) present in only
25% of cases. Mothers-in-law normally support their daughters-in-law
during delivery, while husbands have the final say in financial
decisions about whether any further care is sought.
In Nepal the blood and bodily secretions associated
with childbirth are widely viewed as unclean and polluting. As
a result, most people are reluctant to help women who require obstetric
assistance. This helps to explain the protests made by men in the
community and transport workers when asked to carry women in labour
The attitudes of women themselves towards pregnancy
are largely shaped by 'laj' (shame and fear of loss of
dignity and prestige). This becomes an important factor from the
start of a girl's menstruation and has a powerful influence
on most of her social interactions. It is partly for this reason
that many women do not talk about any pregnancy-related problems
until complications have set in.
Obstetric difficulties that arise, including those leading to maternal
death, are generally attributed to fate, karma, witchcraft or bad
spirits. Witches and spirits, such as 'bhut-pret', are
thought to be the single greatest danger during pregnancy and,
as a result, women tend to downplay their condition in order to
avoid attracting such supernatural forces. For this reason, 'Guruwas'
(traditional healers) are often called out during labour.
traditional healers, TBAs
and, possibly, health post staff are the most likely people to
support a woman during an obstetric emergency. Husbands generally
know little about childbirth, feel that it is not their business
and leave decision-making to older women and traditional service
deeply engrained attitudes and practices cannot be changed overnight,
even with the improved availability of essential obstetric care
(EOC) services. Therefore, NSMP uses a variety of communication techniques, tailored to each local
cultural context and implemented by local partners. These aim
to improve levels of knowledge about danger signs, change attitudes
in favour of women's decision-making and raise the status
of women both within households and in society at large.
mothers are encouraged to work as catalysts for change and to uphold
good EOC practices.NSMP monitors
the change in knowledge, attitudes and perceptions that result
from such activities through Knowledge
Surveys and the community-based Key
Informant Monitoring Tool.