Nepalese Health Experts Blame Poor Nutrition for Rising Anemia Rates Among Pregnant Women

KATHMANDU, NEPAL – Elina Gauchan, 18, nurses her baby while seated outside the steps of her house in Kathmandu, Nepal’s capital. Her daughter was born in April.

Gauchan was born to a poor family in Okhaldhunga district, a mountainous rural area in eastern Nepal, she says. She came to Kathmandu less than two years ago in hope of finding a job. She met her future husband at the employment agency where he works.

She did not know until after she married her husband that he had another wife, she says. (Her husband declined to comment on his actions for this article.) His first wife and their son live in the same house as Gauchan, their daughter and his parents. Although polygamy is illegal in Nepal and is not widely accepted in society, it does exist.

Gauchan became pregnant soon after she and her husband wed last year. When Gauchan went to Paropakar Maternity and Women’s Hospital in Kathmandu to give birth, the doctor diagnosed her as anemic, she says. She lost some blood after delivering and received a blood transfusion.

She had never heard about anemia and did not understand the importance of eating nutritious food with sufficient iron during pregnancy, which helps to reduce anemia, she says. She did not have regular prenatal checkups, which could have detected her anemia at an early stage.

Her husband took her to the hospital just once, in her sixth month of pregnancy, because she started to suffer dizziness and blackouts, which are symptoms of anemia. The doctor prescribed medications but did not explain her condition or address its causes.

Gauchan is thankful that her daughter was born healthy and was not affected by her anemia, she says.

Six weeks after giving birth, Gauchan continues to be anemic, she says. She does not go for regular checkups because her husband does not take her and she is not familiar with the city. But she takes the iron and folic acid tablets prescribed by a hospital doctor. Following nutritional guidance she received at the hospital, she is eating green vegetables and greens, which are high in iron.

Anemia is a condition in which the number of red blood cells – or the oxygen-carrying capacity of the blood cells – is insufficient to meet the body’s needs.

“Anemia is a common problem in Nepalese women,” says Dr. Pushpa Chaudhary, director of Paropakar Maternity and Women's Hospital. “It is caused when women do not get food enriched with iron and vitamin B12, by intestinal worms, or excessive bleeding during pregnancy.”

Pregnant women are increasingly suffering from anemia in Nepal, despite the government’s effort to supply them with iron supplements.

In Nepal, anemia is especially common among young children and pregnant women, according to the 2011 edition of the Nepal Demographic Health Survey, a national survey carried out every five years by the Ministry of Health and Population. Nearly half of all pregnant women surveyed in 2011 were anemic, compared with 33 percent of women who were neither pregnant nor breastfeeding.

The UNICEF South Asia office in Kathmandu does not have recent data on anemia rates regionally. The latest global anemia analysis by the World Health Organization, published in 2008, sources data from Nepal from 1997-1998.

The WHO analysis, covering 1993 to 2005, found that about 40 percent of pregnant women globally suffered from anemia. Prevalence among this population was highest in Africa, followed by Southeast Asia. The report ranked Nepal among the one-third of the world’s countries in which prevalence among pregnant women was severe.

“During pregnancy, women need to double their normal nutrition to allow for the growth of the baby in their womb,” Chaudhary says. “If they don't get proper nutrition during pregnancy, or have heavy bleeding after the delivery, there is a high risk of getting severe anemia, which can lead to death.”

Anemia can cause pregnant women to feel extreme tiredness, difficulty breathing, dizziness or fainting, headaches, chest pain or elevated heart rate, Chaudhary says. Severe anemia can cause premature birth, birth defects, or even maternal and neonatal death.

A diet high in green leafy vegetables, dairy products and red meat can prevent and cure anemia, Chaudhary says. Iron and vitamin B12 supplements and folic acid tablets can also raise hemoglobin levels.

But lacking information about the diet required during pregnancy and the cooking methods that retain nutrients, even women who can afford nutritious food often do not eat properly during pregnancy, Chaudhary says.

Young mothers are at a high risk of getting anemia, Chaudhary says. When a young woman becomes pregnant, she must obtain sufficient nutrition to support her own growth as well as the growth of her fetus.

The Nepal Demographic Health Survey does not break down anemia rates among pregnant women by age. But it does report that anemia is more prevalent among teenage girls in Nepal. Nearly 40 percent of girls and women ages 15 to 19 who were surveyed showed signs of anemia, compared with 35 percent of respondents ages 15 to 49. Nearly one-third of Nepalese women have had at least one child by the time they turn 19.

“Families do not pay attention to the nutrition of teenagers in general,” says Dr. Aruna Uprety, a public health specialist who works as a freelance consultant with nongovernmental agencies and research organizations on adolescent and women’s health and nutrition issues in Nepal. “In Nepalese culture, women eat last, after all the men have eaten, and they eat what is left. Many females are not self-dependent and have to depend on others in the family for their food even during pregnancy. These practices also contribute to anemia.”

Women living in rural areas of Nepal, like Gauchan, are also at a higher risk.

“Although the problem is seen both in cities and in the rural areas, the data shows that the number of women with anemia is higher in the villages,” Chaudhary says.

As of 2011, 36 percent of women living in rural areas had anemia, compared with 28 percent of women living in urban areas, according to the Nepal Demographic Health Survey. Further, the rate of teenage pregnancy is twice as high in rural areas than in urban areas.

In rural areas, women can access iron-rich vegetables in their own gardens, Chaudhary says. But lacking knowledge about nutrition, they give little thought to their diets.

In 2004, the Ministry of Health and Population launched the Intensification of Maternal and Neonatal Micronutrient Program, under which the government provides free iron supplements to pregnant women.  

Despite those efforts, anemia prevalence among pregnant women increased from 42.4 percent in 2006 to 47.6 percent in 2011, according to the Nepal Demographic and Health Survey from those years.

“Though the government is supplying iron and folic acid to pregnant women across the country, the percentage of anemic women is not decreasing,” Uprety says. “The reason for the increase in anemic patients is lack of awareness about nutrition they need to have during the pregnancy.” 

Chaudhary agrees.

“Most of the pregnant women in the remote areas of Nepal have tablets instead of having a nutritional diet,” Chaudhary says. “Only taking the tablets can't fulfill the hemoglobin level in the body. The body needs protein and calcium from food to enrich the quantity of blood.”

Many women also fail to have timely medical checkups during pregnancy, so anemia often goes undetected and untreated in the early stages of pregnancy, he says.

Because many women have been unaware of the government program, the government has mobilized community health volunteers to raise awareness among women in rural areas of the high risk of anemia and the importance of good nutrition and regular checkups. The volunteers also distribute free supplements.

Q&A With Elina Gauchan

Yam Kumari Kandel: You became a mother at 18, during your first year of marriage. How did you feel about becoming a mother at that age?

Elina Gauchan: My parents’ financial status was very poor. I came to Kathmandu a year ago to earn money. My husband said that he would send me for foreign employment but cheated me into marriage. He already had a wife before me. I got pregnant right after I got married.

Now, I feel very proud giving birth to my daughter. However, I neither had planned on getting married nor having a baby. Both happened unexpectedly. I worry about how I will raise my child and send her to a good school. I am thinking about good schooling and a balanced diet so that she will grow up healthy.

YKK: In what ways did you care for yourself during your pregnancy? What or who were your sources of information about prenatal care?

EG: I became pregnant without any desire or plan. It happened to me all of a sudden. I was not mentally prepared to be a mother. That's why I did not know what kind of care was required during pregnancy.

Even during pregnancy, I ate the same food I used to eat in my own kitchen. I cared for myself as I used to care before my pregnancy.

YKK: How did you take care of your health?

EG: When I was hungry, I used to eat chapatis [grilled flatbreads], potato stew and rice. Whatever I found in the kitchen, I ate. I hardly ate meat – only once every two weeks. … I did not take care of myself in any special ways while I was pregnant. I had no idea about nutritional food before.

YKK: Did you work as much as before or did you take rest during your pregnancy?

EG: How could I get time to take rest?! I have only my in-laws in my house, and they are really old. If I did not work, “Chulo ma aago nai baladaina”[Nepali proverb that translates as, “Fire will not be lit in the kitchen,” meaning, “There would be no cooking”]. There are many people visiting our house. I had to feed them as well. How could I get time to rest?

So I didn’t get time to take any rest when I was pregnant with my daughter. I even used to wash a pile of dishes before going to sleep at night.

YKK: What or who were your sources of information about prenatal care?

EG: I found out that I was pregnant when I missed my period. The people at home did not give me any advice when they heard about it.

My husband's first wife also did not teach me to take care of myself. I used to work all the time, just as I did before. I could not take any rest, although my neighbors told me not to do heavy work and to rest.

YKK: What were some of the health problems you faced during your pregnancy? Could you describe how they affected you?

EG: I got very weak from the beginning of my pregnancy. I vomited many times. I used to feel dizzy when I stood up after being seated for some time. While working, I felt like I would faint.

I still have these problems. I did faint maybe two or three times while working. My limbs would get tired when I did heavy work, and also my heart rate would increase.

What could I do even if I knew that I was weak? I feared that my husband and in-laws would think that I had some kind of illness, so I did not tell them about my condition.

YKK: Did you seek medical attention when you were having these health problems during your pregnancy? If not, why not?

EG: During the sixth month of my pregnancy, I fainted while working. I think my husband took pity on me, so he took me to Tribhuvan University Teaching Hospital. The doctor told us that my hemoglobin level was low and prescribed some medicines. My husband bought the medicine for about three months. After that, he did not buy the medicine and I did not know where I could buy it.

My mother-in-law used to say that such experiences were quite normal. My husband was always busy with his work in the employment agency. As he had another wife, he did not take care of me. My own family could not travel to Kathmandu from Okhaldhunga to look after me. I used to get busy with the household chores. I had no choice but to bear it all.

YKK: Can you tell us about the birth of your child and what happened when you went into labor?

EG: I was washing the dishes when my water broke. Water started coming out of my vagina, and it wet my clothes. I started having cramps.

When my husband saw me in pain, he called for the ambulance. I reached the hospital at 9 a.m. Although my labor started at 5 in the morning, I gave birth to my daughter at 11 at night.

I thought I would die because of the pain. My pain subsided when my daughter was born, but the bleeding did not stop. I was nearly unconscious.

YKK: After the birth of your child, what did you learn about the medical condition you are suffering from?

EG: After the birth of my child, I lost an excessive amount of blood from my body. I felt very weak. So it was very hard for me to sit, stand and even to eat properly.

Having lost excessive blood from my body, I was given two packets of blood. Then I found out from my doctor that I have anemia.

YKK: What did the doctor tell you about anemia?

EG: The doctor said that because I did not consume nutritious food, my body was not producing sufficient blood. Therefore, I got weak. The doctor and nurse told me to take nutritious food that helps to produce enough blood.  

YKK: How is the health of your daughter? Did she suffer any consequences because of your anemia? If so, what kind of treatment has she been receiving?

EG: I found out from the doctors that my daughter is healthy, and it was my good luck! The children of mothers with anemia have low birth weights and are at risk during delivery.

The doctor also told me to put my daughter in the sun; otherwise, she might get jaundice. Therefore, I place her out in the sunshine for two or three hours every day. She has not received any other medical treatment.

YKK: What kind of information did you receive from hospital staff about ways to combat anemia, such as eating nutritious food?

EG: My doctor said that the only problem that I have is low hemoglobin level. Apparently, the lower hemoglobin causes weakness! They also told me to consume nutritious food.

YKK: Did you know your hemoglobin level?

EG: No, I did not know. But, the doctor told me that I had low level of blood and I was given two packets of blood.

YKK: What kind of nutritious food did they ask you to take?

EG: Meat, eggs and fish as much as possible. Also, green leafy vegetables, fruits and dairy products.

YKK: What is your access to nutritional food like? How do you judge the nutritional value of the food you eat?

EG: We do not have a buffalo at our house to get milk and yogurt. My husband’s income is not enough to buy these things. And I do not have any other income. It is difficult to survive with a single person’s income.

We can hardly afford to eat meat once or twice a month. Also, in a family of seven people, I hardly get few pieces of meat when we distribute a kilogram among ourselves.

We don’t have that much money to buy fruits. If I have to distribute the food to everyone, then it is better not to bring it [home] at all.

YKK: So what do you eat now in your meals in the morning and evening?

EG: I have tea and bread for breakfast. For lunch and dinner, I mostly eat lentils, rice and potatoes. I like potatoes very much. I do not like meat that much. I simply boil it if I have to eat it.

YKK: How do you judge the nutritional value of the food you eat?

EG: I do not know anything about it. I only need food to fill my stomach. However, I had heard that eating meat, fish and apples gives strength.

YKK: How prevalent is anemia among young women in your community when they become pregnant? Have any of your friends or relatives suffered similar experiences during their pregnancies?

EG: I did not know what anemia is. But when I was in the hospital for my delivery, I saw another woman who was being given blood like I was. I thought that she had a problem like me.

I have not heard of anyone else who had a blood problem like me. Sometimes, women in my village tell me that they have weakness and they also feel dizzy.

YKK: If you become pregnant again, in what ways do you plan to prevent your condition from worsening or harming your baby?

EG: (Laughing) I have not planned for another baby yet. And if I conceive, I would eat whatever I have in my house for the health of my baby.

I would ask my husband to bring nutritional food, especially for me. And I will remind him about my first pregnancy, when I suffered badly. I think after that he would be concerned about my health condition.

If I get dizzy with weakness, I will go to the hospital. I will take the iron supplement regularly. If I had early diagnosis, I would not have been this weak. If I get strong, my daughter will also become strong.

YKK: What health problems do you still suffer because of your anemia? What is your access to care like?

EG: I still feel dizzy when standing up after sitting for a while. 

YKK: What kind of work do you do at home?

EG: Although we are seven people at home, my husband works in an employment company and we get more than five people [job seekers who cannot afford lodging] every day to live in our home. I have to cook and feed them and also wash the dishes every day. By the time I finish, I feel like I would faint due to tiredness.

I feel very tired and lethargic even if I do not work much. I feel like sleeping all the time.

YKK: What is your access to care like?

EG: I sometimes eat meat, fish and leafy green vegetables.

YKK: How often do you eat meat and leafy vegetables?

EG: Even if we bring home some meat, I hardly get two pieces. So it is better not to bring it at all!

YKK: In what ways do you plan to take care of your own health and that of your child in the future?

EG: I will not endure like I did before. I will visit the health institution as much as possible. I will take the medicine prescribed by the doctor.

I will eat whatever I find at home and will not stay hungry. If nobody else makes food for me when I am hungry, I will cook for myself, as I always do.

I will also try my best to have nutritional food like fish, meat, eggs, milk and yogurt as well as fruits. Even if my husband would not care for my nutritional diet, I will ask him to bring the kind of food that is required by my small baby.

YKK: What advice would you give to other teenage mothers who are pregnant with their first children? How can they learn from your experience?

EG: I do not know how to give advice as doctors. But I can share what I suffered with them.

YKK: What will you say to them?

EG: When I was pregnant, I did not go for regular checkups. If I had gone to the health posts, I would have gotten the iron capsules for free. I would have known about the importance of taking nutritious food. And I would not have suffered during delivery.

I would have tried to eat whatever the doctor advised me to eat. I would have increased the level of hemoglobin in my blood. After that, I would not have suffered from weakness during delivery. I would say these things.

GPJ translated this article from Nepali.