Maternal healthcare: Policies, culture and practice in Nepal
By Prof Padam Simkhada and Prof Edwin van Teijlingen
Nepal has made significant progress in improving the health of women and achieved a striking reduction on maternal mortality. Despite difficult terrain, conflict and political turmoil, it is one of the few countries that managed to achieve Millennium Development Goal 5 on maternal health in 2015 .
A number of policies and initiatives have been introduced in Nepal over the past three decades to help reduce avoidable risk factors. The main programme initiatives focus on developing the infrastructures for normal delivery and emergency obstetric care, standardising maternity care, strengthening the maternal health work force, establishing functional referral mechanism, promoting inter‐sectoral coordination and collaboration and research on safe motherhood.
Nepal has been concentrating its efforts on maternal health through several policies and programmes. The National Health Policy 1991 , the Second Long Term Health Plan 1997-2017 , National Safe Motherhood Policy Plan 2002-2017 , all aim to reduce mortality and morbidity among women during pregnancy, childbirth and postnatal period . Similarly, the National Policy on Skilled Birth Attendants 2006  and the Health Long-Term Plan 2006-2017  aim to reduce maternal and neonatal morbidity and mortality by ensuring availability, access and utilization of skilled care at every birth. Whilst the Nepal Health Sector Programme Implementation Plan II (NHSP-IP II: 2010 – 2015)  focus on maternal health care provider training to fulfil the demand to expand emergency obstetric care.
The Safe Delivery Incentive Program (SDIP) under the Aama Program 2012  offered a cash incentive to women who had an institutional delivery, this was initial funded by the UK through DFID. SDIP also provide a payment to health facilities for providing free delivery care. Similarly, it also provide cash incentives to women who attend at least a minimum of pour ANC (antenatal care) visits and to Health Worker who visit women’s home and conduct a home delivery. The National Health Policy 2014  emphasises the training and provision of staff, for example the provision of a doctor and a nurse in every rural municipalities and an Auxiliary Nurse Midwife in every electoral ward. However in the NDS of 2016 only 58% of births were attended by a skilled birth attendant. It is worth noting that Nepal does not formally recognise midwifery as a separate profession from nursing.
The inequity remains a huge issue in Nepal, and further progress in maternal health will require targeted interventions to reduce health differentials and reach underserved populations. Similarly, the quality of facility-based care needs to be improved. Likewise, the gap in human resources for health, including deployment and retention issues, need to be reduced. Community-based interventions and women empowerment seem effecting intervention to improve the maternal health and healthcare system needs to invest more on addressing the cultural practices around childbirth and the postnatal period, and the stigma around menstruation.
Nepal is in many ways quite traditional and maternal health is often seen as a women’s issue. Pregnancy and childbirth are socio-cultural events that carry varying meanings in Nepal. These are often translated into social expectations of what a particular society expects women to do (or not to do) during pregnancy, birth and/or the postnatal period. In many traditional rural communities and less educated urban communities many taboos and stigma attached to menstruation, pregnancy and childbirth . A recent article "Dirty and 40 days in the wilderness: Eliciting childbirth and postnatal cultural practices and beliefs in Nepal" highlighted that (a) birth was perceived as ‘polluting’; (b) postnatal women were perceived as being ‘polluted’; and therefore isolated and (c) cleansing rituals were required for mothers after the resting/isolation period. In Nepal, it is considered lucky to cut the umbilical cord on a coin. The treatment of umbilical cords is very ritualistic, and various household tools are used to cut and tie the cord. The placenta is generally buried, to protect the baby. If the placenta is retained the practice is to try to make the woman vomit to help expel it.
"If placenta is not expelled, a piece of cloth is inserted/packed in woman’s mouth so that she has nausea. That helps to expel the placenta". A woman from rural community
"Keep her (the mother) warm, give hot food, oil massage, and keep in the sun, burn lamp on 6th day and rice feeding on 5th month for daughter and on 6th month for son".
The practice of isolating women during their period remain across the country in differing forms. In some rural areas and some ethnic groups, women cannot be in their own homes when they are having their period. In some culture, women can be in the house, but not allow to cook or go to the kitchen or temple. They are also forbidden to touch other people or cattle and sometime women are not allowed to touch growing fruit and vegetables. Many girls miss school on days they are having their periods.
We need to remember that policies are easier to change than behaviour, especially behaviour that is embedded in traditional culture. Health policies by themselves cannot do very much reduce traditional views. Thus there is a need to reduce the more general problem of gender inequality. With a cultural and socio-economic shift towards a more equal society old fashioned believes about menstruation and childbirth will slowly disappear. Although we need to be careful not to lose the better aspects of traditional culture much higher breastfeeding rates at six months than in the UK.
It is clear improving maternal health is a major focus of the current national development plan in Nepal. Policies and policy initiatives are often good on paper in Nepal but the weakness regularly lies in their implementation. Understanding childbirth values and beliefs of specific cultural groups can promote culturally appropriate evidence-based care. Cultural postnatal practices can be harmful or ineffective, but changing deep-rooted practices, often with religious origins, is challenging even among educated women. Understanding the social cultural environments should be part of health providers training to change these behaviours or incorporate them into the care. Policy and programme should address these issues as well. A gap in knowledge surrounding social cultural conditions may explain the failure of some health policies and programmes to address such issues.
Both authors have published over 40 papers on maternal health issues in Nepal. Padam Simkhada is currently working as a Professor of International Public Health at Liverpool John Moores University, UK and Edwin van Teijlingen is a Medical Sociologist and Professor of Reproductive Health Research at Bournemouth University, UK. Both are visiting Professor at Tribhuvan University and Pokhara University of Nepal.