In the slanted golden light of late afternoon, Lalu Nepali beat rice with a long wooden mallet. The wood extended a foot above her head, and she dropped it onto her pile of grains, separating rice from the hulls with a rhythmic thud, thud, thud. A white scarf was wrapped tightly around her midsection as if to hold in her nearly bursting belly. She grunted at the exertion with each strike. Thud, grunt, thud, grunt. Nine months pregnant, she was due any day.
Nepal is viewed as one of the success stories in the global effort to improve women's chances in pregnancy and delivery. The United Nations created the Millennium Development Goals to measure improvements in various aspects of life in developing countries, and the fifth goal is to reduce by 75 percent the rate of women dying around pregnancy and delivery by 2015. Almost nowhere has this been accomplished, as changing birth outcomes has proven more challenging than anticipated.
Nepal is one of just a few countries that has already significantly reduced maternal deaths, and is on track to achieve MDG 5. But investments in the health system are crippled by engrained gender disparity. Until the status of women improves, childbirth will remain a dangerous labor.
The Nepali government has worked hard to improve their maternal health statistics, and arranged national policy around the international development agenda. There is a rigorous family planning program which has helped lower the average number of children women have from 4.6 in 1996 to 2.6 in 2011. Government spending on health tripled between 2006 and 2011. Abortion was legalized and reproductive rights were specifically included in the interim constitution of 2007, and more women are birthing in health centers, motivated in part by a government program that pays women to birth in clinics.
Lalu lives deep in Far-Western Nepal, a two-day's drive and a world away from the bustling capital where health policy is hammered out. Her village is stacked in tiers on the edge of a mountain, jutting over a deep valley. Across Achham, the endless hills are carved into terraces of fields planted with potato and wheat seedlings.
To get to her local clinic Lalu had to walk one to two hours, depending on her pain, along a path cut out of the side of the mountain, slowly ascending to the main dirt road. Then she had to double back on the opposite face of the mountain, descending a slippery, pebble strewn path. The health post is off the main road, past a tiny town comprised of teashops selling little more than hard candies and instant noodles. A steep, rocky path leads down to the clinic; it feels like a landslide waiting to happen.
But Lalu made the trek several times throughout her pregnancy to take advantage of prenatal checkups, and the 100 Nepali Rupees ($1.03 USD) she earned for each visit. A central part of Nepal's efforts to make labor safer has been to entice women to birth in clinics and hospitals. At Lalu's local clinic, a fresh-faced midwife named Parvati Kayat has received laboring women desperately trying to reach the health clinic to get the seemingly nominal stipend. "Some women are so poor that even if they deliver on the way they struggle to get here just to get the 1,000 Rupees ($10.57)," she said. The program pays between 500 and 1,500 Nepali Rupees, or $5 to $15 USD, depending on the region.
Lalu planned to birth at the clinic this time, something other women in her village had started doing in the past few years. "Everybody says it's more comfortable there," she explained.
Survival, not comfort, was her priority in earlier births. Most women in her village can relate a horrible birth story of their own, or a relative's near-death experience during birth. It makes for anxious pregnancies, and inspired Nepal's women's health activists to push for policy change.
Women in this part of Nepal practice a tradition called chaupadi where each month they segregate themselves from their families during menstruation. Menstrual blood is considered impure and allowing women in the house is believed to bring devastating bad luck.
In the village, most homes are two stories, made of wood beams and mud. Upstairs are the bedrooms and the kitchen, set off from a balcony that serves as a hallway, terrace, and clothesline. Downstairs is the stable; the ground is covered in straw to soak up pools of excrement from the cows and buffalo. When women are menstruating, and historically when they gave birth, they stayed downstairs, next to the cattle, in grimy rooms that would not be tainted by their blood (even so, the rooms were purified after the birth or at the end of menstruation).
Women birthed alone or with the help of female relatives or traditional midwives, so women prayed and hoped for a simple labor, because if there were complications there was often little to be done. At the last count, three quarters of women in the Far Western Hill region still gave birth at home.
Lalu had two surviving daughters, but in between there had been a son. He was born in the stable, in a long and painful delivery, but he was breach and while his body emerged, his head was stuck in the birth canal for hours. By the time he was born he was dead; Lalu also nearly died.
Lalu's decision to follow her neighbors and birth in the clinic shows the implications of Nepal's investments in maternal health, but Kayat, the midwife, said she still only sees between 10 and 14 births per month. And she said there is little comprehension among the women about the importance of birthing in the clinic's somewhat dark and dingy "DELIVARY ROOM" (as it is labeled). "There are a few women who understand that due to excessive bleeding they can die, so they should deliver here," Kayat said, "but the majority just come for the money."
Kayat and other health professionals see a deeper social issue underlying Nepal's lingering maternal health challenges. Kayat works with women she sees as high risk, jeopardized by poor nutrition and manual labor. "I tell them don't carry a heavy load, take as much rest as possible, eat green vegetables, yellow fruits, legumes, and beans." But, she admitted, "women don't have a voice. It feels bad. Some women say they eat, but their weight says something else ... some women, when I counsel them ask 'how can I get those things? Where can I get those?'"
"This is not only a health problem, this is also an empowerment issue, a gender problem," explained Samita Pradhan, a women's rights activist at the Centre for Agro-Ecology and Development in Kathmandu. Nepal ranks 157th out of 186 countries on the United Nation's Gender Inequality Index, and women in the Far West have the least say in household decisions of any region in the country. A government study of the maternal health program found the most births taking place in health centers occurred in areas of the country where women were more empowered and more economically stable.
Throughout her pregnancy, Lalu was consistently doing some kind of physical labor; chopping wood with an axe, vigorously bathing her daughter, lugging huge piles of firewood, cooking dinner in a smoke clogged kitchen. She worried about her baby and about incessant pain in her side. "The hospital told me not to work, but what can be done?" she asked. "Even if I can't work I have to." Lalu said there was no one to help her, "there is one old mother-in-law and my young daughter, no one else."
Most times I saw Lalu, her husband Ghagane Nepali was also there, seated in the yard, sometimes helping the children study, sometimes working with his sewing machine, practicing to become a tailor. In this remote village gender roles are so entrenched that it was inconceivable for Ghagane to do household labor — considered women's work — even with his wife nine months pregnant.
While Lalu physically kept the household going, Ghagane's role was to provide for the family. But in Achham there is almost no employment for men; the village is full of women, boys, and the elderly or sick. The healthy men in town are listless migrants on vacation, with nothing to do between trips to India where they work exhausting hours for little pay and pile into cramped rooms with other transitory laborers.
Ghagane recently returned home himself. He was the only man of his generation living in the family compound. "I came back because we should have at least one brother at home," he said. "I like Nepal but if you want to support your family you have to go to India." Many of the men who return home while away their time, showing off new cell phones bought abroad and drinking tea, but Ghagane was more industrious and was trying, with his sewing machine, to find some way to be productive for the family. But despite his work ethic, he stayed seated as Lalu grunted and panted her way through her chores.
"Pregnancy and after delivery is a very critical time for women. If they are taken care of, they will be prevented from so many problems, but even [during] those periods they have to carry firewood, cow dung, manure, all that. They can't say 'I am pregnant,' or 'I am menstruating,' or 'I have a small child.' They have no voice at all," explained Pradhan, the activist in Kathmandu. "It's very complex, only health [policy] cannot address this issue ... maternal health issues [are] related to social issues"
Lalu ended up birthing a healthy son at the clinic. She is part of Nepal's success story: in her lifetime she moved from birthing alone in a stable to birthing with a trained midwife at a clinic, and she survived. But her role in the home and her physical labor until the last moment point to the underlying issues Nepal will have to address to broaden women's chances for health.