This article provides a background on Nepal as a whole, with a focus on the nation's childbearing and birthing practices. While modern Western medicine has disseminated across the country to varying degrees, different regions in Nepal continue to practice obstetric and newborn care according to traditional beliefs, attitudes, and customs.
Background Health and illness theories Indigenous Nepali theories of illness differ from that of the modern Western world. They do not believe in the germ theory; instead, they believe that illness is caused by malevolent powers that enter the body, disturbing the normal balance and creating sickness. It is up to the healer (dhami-jhankris) to try to release the malevolent power that is causing disease and restore balance in the body system to make it function normally again.Khatry, P. K. The Nepalese traditional concepts of illness and treatment. DADA Rivista di Antropologia post-globale [Online]. Retrieved from http://www.dadarivista.com/Singoli-articoli/2011-dicembre/pa3.pdf These indigenous beliefs are similar to the faith healing traditions still practiced today. Faith healing is based on the belief that illness is due to attacks by different types of spirits. The healers must identify the type of spirit and make an offering to appease the spirit or forcibly remove the spirit with a spirit bone (usually a human femur). These rituals often include colorful costumes, chanting, singing, dancing, and drumming, as well as a sacrifice of a rooster or a black goat. These ceremonies are done by dhami-jhankri (shamans), pandit-lama-gubhaju-pujari (priests of different ethnic and religious groups), and jyotishi (astrologers).Shankar, P. R., Paudel, R., & Giri, B. R. Healing traditions in Nepal. Online Journal for the American Association of Integrative Medicine. Retrieved from http://www.aaimedicine.com/jaaim/sep06/Healing.pdf
There are two other main healing traditions in Nepal, namely Ayurveda, Tibetan medicine, and faith healing. Ayurveda is based on the tridosha theory of disease, where the three doshas, or humors, are Vata (wind), Pitta (gall) and Kapha (mucus). Disturbance is the equilibrium of these humors results in disease. The traditional healers can be divided into faith healers and medical providers. The medical providers include Baidhya-Kabiraj, who use elixirs, metal preparations and herbs to treat illness, and Jadi-butiwala, who only use herbs for treatment. Tibetan medicine (gso ba rig pa) is based on the belief that the physical world, including our bodies, are a product of our individual perception, and it is the mind that brings on illness to the body. The Tibetan medical practitioners, Amchis, help direct the patient towards increased self-awareness to restore balance and harmony between the body and the forces of the universe.
Health statistics The current total population sex ratio in Nepal is 0.98 males/female. Female life expectancy at birth in 68.92 years, compared to 66.18 years for males. The fertility rate is 2.24 children born per woman, and the birth rate is 20.64 births per 1,000 people. The mother's mean age at first birth is 20.1 years old. 49.7% of the population use contraception."The World Fact Book: Nepal". Central Intelligence Agency. Retrieved from It is unclear what the abortion rate is in the country, likely because it is considered taboo, so women are less likely to report it."Sharing experiences and changing lives." PATH. Retrieved from http://www.path.org/projects/safe_abortion_nepal.php
Maternal mortality rates have dropped significantly from 539 per 100,000 live births in 1996 to 258 deaths per 100,000 live births in 2015. For this achievement, the country has been honored at the 2010 Millennium Development Goals Review Summit. Leading causes of maternal mortality are postpartum hemorrhage (46%), obstructed labor (16%), complications of pregnancy induced hypertension and eclampsia (14%), and puerperal sepsis (12%) in 2015. 67% of maternal mortality occurs at home, 11% occurs at a health facility, and 11% occur on the way to a health facility. 90% of maternal deaths occur in a rural setting.Padhye, S. M., & Lakhey, B. (2003). "Brought dead" - cases of maternal mortality. Kathmandu University Medical Journal 1(2): 184-186. Retrieved from
There has been an increase in the percentage of births attended by skilled personnel (doctors, nurses, midwives), from 4% in 1990 to 53% in 2015."Country health profile: Nepal.” [PDF]. (2008). World Health Organization. Retrieved from http://www.who.int/gho/maternal_health/countries/npl.pdf Skilled birth attendance (SBA) in the urban setting is 72.7%, compared to 32.3% in the rural setting. SBA among the poorest 20% of the population is 10.7%, whereas among the richest 20% of the population, it is 81.5%.“Nepal: Statistics.” (2013). UNICEF. Retrieved from http://www.unicef.org/infobycountry/nepal_nepal_statistics.html
The under-five mortality rate has dropped from 142 deaths per 1,000 live births in 1990 to 42 deaths per 1,000 live births in 2012. Infant mortality (under-one) is 39.14 deaths per 1,000 live births. Neonatal mortality rate is 24 per 1,000 live births.
Pregnancy behaviors and beliefs Prenatal care According to UNICEF, 58.3% of women have at least one antenatal care visit and 50.1% have at least four visits. However, other studies have shown coverage in rural communities to be as little as 29% and upwards of 79% in more urban areas. On average, each session lasts about 10 minutes, with an emphasis on health education and counseling. Physical examinations and blood pressure measurements were also performed in 85-95% of cases, but biochemical tests including urine analysis and sero-testing for syphilis were not always performed. The main topics discussed during the visit ranged from nutrition, personal hygiene, and general reassurance that "everything is all right". Fortunately, 76% of women were informed of signs of pregnancy complications.Ministry of Health and Population, New ERA and ICF International. (2012). 2011 Nepal Demographic and Health Survey: Key Findings. Kathmandu, Nepal, and Calverton, Maryland, USA: Ministry of Health and Population, New ERA and ICF International. Retrieved from https://dhsprogram.com/pubs/pdf/SR189/SR189.pdf Similarly, taking a woman's history focused solely on the current pregnancy, rather than including questions about possible previous experiences. As such, complications were never asked nor were they consistently followed up with referral practices in the rural communities. Preventive interventions have vastly improved over the past two decades. Eight in ten women now take iron supplements during pregnancy. Though improvements can be made as only 55% took intestinal parasite drugs.
Within the past two decades, the government and NGOs have come together to tackle the low prenatal care rates in an effort to improve maternal and child morbidity and mortality outcomes. One such tactic, the Safe Motherhood Initiative, is providing financial incentives for pregnant mothers to come to their prenatal care check-ups. These types of programs pay anywhere from 500 and 1,500 Nepali Rupees or $5 - US$10, depending on the region.Gaestel, A., & Shelley, A. (2013). What pregnancy is like in Nepal. The Atlantic. Other incentives include providing free services for maternal related issues and having a 24-hour delivery service. Through the national increase on funding of these particular health concerns, there have been large improvements concerning the 5th Millennium Development Goal (as evidenced under Health Statistics).
However, modern medicine continues to struggle against the traditions upon which antenatal care has previously been done. Excluding geographical access, some other reasons quoted for non-use of maternity services include: cultural barriers, perceived low quality of care, perceived discrimination of rural people, and lack of perceived health gain. Many pregnant women feel threatened, unaware, or uneducated about the benefits that a prenatal check-up could bring. For some, the risk-benefit of one day of work and one day of prenatal check-ups is the deciding factor. For example, a woman who works in the agricultural fields may not feel it is worth sacrificing a whole day's work in order to seek antenatal care, especially in the absence of a mother-in-law's perceived concern regarding the pregnancy.
Social expectations Thus, this feeling of "going through it alone" is paramount throughout the entire childbirth experience. Even if women are anxious about the birth outcome (survival or death), they emphasized that it was something they had no control over, believing birth is in God's hand. As such, pregnancy and birth needed no preparation. Due to the societal expectation of women as bearers of children and careers of the family, the practice of giving birth traditionally (i.e. vaginally) was safe and even empowering for women if done in a goth (small out-building near the main house or lower section of the main house for animals). Similarly, losing a child was an unfortunate but expected part of continuous pregnancy and childbirth in these villages. Infertility and death was also prevalent and reasoned to be because the gods were angry with them for committing a very serious sin. This natural process conflicts with the medical model and many hospitals and health centers have to negotiate with these local cultural and spiritual beliefs before providing care to these women.
Preparation for birth Overall, women do not prepare much for birth. Especially if they are delivering alone, they will not have the time nor the funds to adequately prepare for labor and delivery. They will, however, work right up until the onset of labor. This is mainly due to the deeply entrenched gender roles that women must do household labor. Even if husbands wished to help lighten the workload, they are unable to do so. This constant movement provides added stress and contributes to the already lacking nutritional status of these women, further increasing the risk for poor birth outcomes.Multicentre study on low birth weight and infant mortality in India, Nepal, and Sri Lanka(1994). New Delhi: World Health Organization, Regional Office for South-East Asia.
Families will sometimes help clear an animal shed in anticipation of labor. Generally, this means moving the animals to another place, sweeping up the dung and dirt, laying down clean dry grass or hay, and covering it with a plastic sheet or blanket.
Some traditional birth attendants and skilled professionals will have a pre-made pregnancy kit ready. The kits contain gloves, a small piece of soap, five squares of gauze, a small blade, three pieces of string, a small plastic sheet, and a sandwich-sized bag. However, this practice is not consistently among TBAs as one study found only 2% used them consistently and correctly.
Extrinsic factors