September 13, 2015
KHOKANA, NEPAL ̶ Khokana, a village of old red brick houses and narrow lanes, is quiet and picturesque. But this traditional village of the Newar people, about 10 kilometers (6.2 miles) from Kathmandu, Nepal’s capital, is in the midst of a revolution.
The villagers here are shedding generations of myths and ancient beliefs to embrace modern healthcare and ensure safe childbirth for their women.
Nanda Keshari Maharjan, 31, gave birth to her son in January at Patan Hospital in Lalitpur District, about 25 minutes by bus from Khokana. The baby, Maharjan’s second child, was safely delivered through caesarian section.
But Maharjan’s first experience of childbirth, in 2006, was very different. She gave birth to her daughter, Suhani, at home, with the help of a traditional midwife. After four hours of labor, the midwife asked Maharjan to try a traditional birthing method: Lying facedown on the floor, Maharjan held an inverted copper wok tightly against her abdomen and pushed. Her daughter was born within 15 minutes.
“I get goosebumps when I think about it now,” Maharjan says.
She knows that she and her baby could have died if this method had caused bleeding in her abdomen, which midwives say can happen. Maharjan says she is grateful to be alive. The baby was healthy, she says, but she still believes that had she given birth in a hospital, the delivery would have been easier and she would have been given a painkiller.
Nepal’s maternal mortality rate in 1990 was 850 deaths per 100,000 live births, according to the United Nations Development Program. A 1996 study by the World Health Organization and UNICEF found that south-central Asia’s maternal mortality rate of 560 deaths per 100,000 live births was the highest in Asia and the fifth-highest of any region in the world.
In 2000, Nepal was one of 189 countries that committed to eight Millennium Development Goals – quantified, time-bound targets to reduce poverty worldwide. The fifth goal, known as MDG 5, included two specific targets: to reduce maternal mortality by three-quarters and to achieve universal access to reproductive healthcare.
Since Nepal committed to the MDG program, the country’s maternal mortality rate has dropped to 170 deaths per 100,000 live births, says Dr. Shilu Aryal, chief of the safe-motherhood program of the Family Health Division of the Ministry of Health and Population.
That exceeded the MDG target of 213 deaths per 100,000 live births.
Nepal is expected to meet all of its MDG 5 targets by December, according to the U.N. Development Program in Nepal.
Aryal attributes the achievements to several government initiatives: expansions and increases in rural health posts, more investment in human resources, increased use of technology, and free child-delivery services, as well as awareness programs.
Cash incentives have also helped. Aama Surakshya Karyakram, now known in English as the Safe Delivery Incentive Program, a government initiative in place since 2005, pays 400 rupees ($3.75) to every pregnant woman who visits a doctor at least four times during her pregnancy, Aryal says. The program also provides a transportation allowance to women living in remote areas and in difficult terrain.
About 308,000 women used free child-delivery services in the 2013-14 fiscal year, Aryal says, citing Family Health Division records. That’s the latest year for which records are available.
Fifty-five percent of all childbirths in Nepal in the 2014-15 fiscal year occurred in hospitals or health posts, Aryal says. An MDG 5 target is to increase that number to 60 percent by December – a goal Aryal is confident the country will reach.
Nepalese health officials say their country’s 7.8-magnitude earthquake on April 25, in which over 8,000 people are estimated to have died, complicated MDG 5 efforts.
The U.N. Population Fund, known as UNFPA, in Nepal estimates that 126,000 pregnant women were affected by the earthquake and its aftermath.
Health facilities in all the worst-affected areas were damaged or destroyed, causing widespread interruption to all health services, says Ghanashayam Pokhrel, senior public-health administrator of the Family Health Division.
The majority of the health facilities in Nepal’s 14 worst-affected districts are now offering services but mostly by using tents and other temporary structures, says Giulia Vallese, UNFPA representative for Nepal. Conditions are suboptimal, Vallese says.
But the quake won’t deter Nepal from reaching its MDG 5 goals, Pokhrel says.
“We are providing them service in such a difficult situation by establishing temporary shelters in the earthquake-affected districts,” he says. “Maybe we are not able to give them luxurious facilities for their delivery process, but we are not compromising on skillful manpower to help them for their deliveries.”
In Khokana, as in many rural areas, conditions that some outsiders would consider suboptimal are normal. That village of 5,000 residents, where Maharjan birthed her first child, preserves Newari culture in many aspects of daily life. Women wear the traditional attire of a long cloth and blouse, and traditional cooking methods and utensils are used to make Newari food from age-old recipes. The village draws many tourists interested in seeing how Newari people live and buying their handicrafts, and Nepalese come to buy mustard oil made using traditional pressing methods. (See our story Nepalese Village Preserves Mustard Oil Tradition Despite Financial Loss.)
There, old traditions are deep-rooted, and change comes slowly. Health volunteers visited Maharjan during her first pregnancy, but she says she and her family weren’t aware that it was important to have prenatal checkups. Since she lives with her husband’s family, having their permission and approval for her hospital visits was important.
“If my mother-in-law and husband had been aware of health checkup during pregnancy and delivery at a health institution, I wouldn’t have suffered so much,” Maharjan says.
At that time, almost all the women in Khokana sought midwives for child delivery, Maharjan says. There was a strong belief that if women went outside the home to give birth, it would bring bad luck and possibly even death. The people believed that the protection of the gods of the Newari people was within their homes and that childbirth had to happen there for the mother and child to be safe.
But education and awareness work by government health officials and village health volunteers have changed the villagers’ attitudes toward giving birth in hospitals.
Maharjan says her family was convinced of the need for a hospital delivery for her second child after seeing other women in the village successfully give birth in a hospital and after the home visits of the health volunteers.
“People are starting to take their daughter-in-law in the hospital for the delivery, so my family also came to realize about the importance of institution delivery and took me to the hospital for my delivery,” she says.
Community health volunteers play a critical role in spreading awareness. Around 52,000 volunteers are working around Nepal, Aryal says.
Among them is Dil Maya Maharjan, 55, who has been a health volunteer in Khokana since 1993. She was the village midwife, and when the District Public Health Office, Lalitpur, offered to train a villager in maternal healthcare, Dil Maya Maharjan was selected by the village elders for the role.
The mother of three adult children, Dil Maya Maharjan says she once followed traditional customs and beliefs in her own childbirth experiences and when she attended to other women.
“I have drunk water from smelly shoes twice while giving birth,” she says. “I feel dirty and fearful thinking about it today.”
Dil Maya Maharjan believes she lost her fourth child, a daughter, because she gave birth at home. Soon after birth, her baby stopped breathing and could not be resuscitated. To this day, the family does not know why the baby died.
“I had to lose my younger daughter after delivery because I could not take care of her medically,” Dil Maya Maharjan says. “Now I feel so bad. If I were taken to the hospital for delivery, then she would be alive now.”
Some women who gave birth at home suffered when their placentas were not expelled, leading to infections, she says. In other cases, women had excessive bleeding.
About three years after her daughter died, Dil Maya Maharjan began to work as a trained health volunteer, and she coordinates monthly meetings for all village women. Now, she personally visits pregnant women and new mothers in their homes.
When she first began her work, she says, many of the women were illiterate, but now the women are educated and more aware of the need for healthcare.
But even educated women are hindered by long-held traditional beliefs.
Sarita Maharjan, 22, has a bachelor’s degree in management. She gave birth to her first child, a son, in February at Patan Hospital.
Her mother-in-law was initially opposed to her visiting a hospital, Sarita Maharjan says. She believed the newborn would be attacked by witches if he were born in a hospital.
“I am a well-educated woman, so I know I have to go the hospital for birthing, but my family did not want to take me to hospital for my delivery because of our cultural practices,” Sarita Maharjan says.
As part of the community education work in Khokana, Dil Maya Maharjan invited Sarita Maharjan’s mother-in-law to attend monthly meetings, where she heard about the dangers of giving birth at home and advantages of hospital births. Volunteers visited Sarita Maharjan’s mother-in-law at home. After a few weeks, she consented to Sarita Maharjan going to a hospital for prenatal checkups, as well as a hospital delivery.
Krishna Bhagat Maharjan, a village leader and the vice principal of the village school, says that until around five years ago, women in the village didn’t go to health facilities to give birth. The work of community volunteers, as well as street dramas geared toward education about hospital services for pregnant women, and radio and television programs have all helped change women’s perspectives in Khokana, he says.
The women have benefited not just from safer deliveries but from safer and more comfortable pregnancies.
Nanda Keshari Maharjan says she had severe anemia during both of her pregnancies. During her first pregnancy, she did not know what to do and was forced to rest regularly because she felt weak and lifeless. In her second pregnancy, she was diagnosed as anemic during an initial prenatal visit to a hospital and given iron tablets and advice on how to improve her diet to combat her anemia. As a result, she didn’t have any weakness or fatigue during her second pregnancy, she says.
All the progress toward healthier, safer pregnancies and childbirths is now overshadowed by trauma from the earthquake. The villagers in Khokana live in fear of another quake, as many of the old traditional brick and wood houses in their village are on the verge of collapse. Nearly 1,000 homes were destroyed, and many of those that remain are propped up by wooden beams, according to Ganga Lal Dangol, secretary of Karyabinayak Municipality in Lalitpur District.
Dil Maya Maharjan lives with her son, as her house was destroyed in the quake. She says there are frequent rumors of another strong earthquake, so many of the villagers, including pregnant women and young mothers, live in makeshift homes built of tin sheets and bamboo sticks.
“I still have fear inside me, but I console the people around me, saying not to worry about an earthquake coming again,” she says.
Dil Maya Maharjan keeps a watchful eye over the pregnant women and mothers with young babies, such as Nanda Keshari Maharjan and Sarita Maharjan.
“I want to do all I can at my level to help my community’s pregnant women to have a healthy life,” she says.
Maharjan is a common last name in Khokana, and none of the sources in this article are related to one another.
Rachana Upadhyaya, GPJ, translated this story from Nepali.