About Maternal-Child Health in rural Nepal – link to Video


May 9 update: link to News article about childbirth in Nepal

April 27th update: Today I learned that there is a Midwives Society of Nepal, they have a web page and (of course) a FaceBook page.

Thought I would pass this along to all my nursing friends who are interested in Nepal but who also are specialists in Maternal-child health. I usually focus on adult care, and this is new to me. There is now a Midwives Society of Nepal, formed in 2010, which I only learned about today.

http://www.midson.org.np/

and they are on FaceBook, of course.

https://www.facebook.com/pages/Midwifery-Society-of-Nepal/208937085792632

Witness Birth in Nepal

Here is a link to a video about childbirth in rural Nepal.

it’s titled “Witness – Birth in Nepal”and it is two years old, though I only just saw it. I consider it to be excellent. it shows: the role of women when the husband works in India; the pressure to conform from the community;the role of lay midwives; the challenges of transportation in Nepal; issues related to HIV; daily life in a village; and also, a brief shot of the “delivery kit” widely used throughout rural Nepal.

It is in English and Nepali with English subtitles for the Nepali parts.

Role of Women

The single biggest problem in Nepal, if you ask me, is the role of women in society.

Here is an excerpt from my book in which I described the practices surrounding childbirth:

Maternity and Nativity

Around this time, Padma was spending every waking moment studying obstetrics. She divided her time between outpatient, inpatient and postpartum. She had learned how to check a cervix, I could sometime see her waving two fingers in the air like imaginary scissors, and I would chuckle at the recognition that she was processing her new found skill. She was now able to track the progress of labor, and evaluate the mother. At the dinner table, we were incredulous when she reported that she had seen an eight-year old boy take a mouthful of breast milk from his mom while they waited o see the mom’s new baby in the postpartum clinic. And she also told us more about childbirth in rural Nepal.

The Maternity Ward at Mission Hospital was not a place where I had much business. I knew that men did not attend childbirth in Nepal. This is true even for the father of the baby. Women don’t attend cremations; men don’t attend childbirth. A simple system.  In the geographic area served by Mission Hospital, there were ten thousand deliveries a year, but only fifteen hundred took place in the hospital. The vast majority of babies were born at the mother’s home.  In a high percent of cases, this really meant that the home delivery took place in a cowshed behind the family farmhouse.

Whoa. It sounded strange to me at first. Many of the houses in Palpa district were constructed of sun-dried bricks made of mud that was usually dug up right on site. In such a house there would be a dirt floor, reinforced by cow manure to give the walking surface a springy smooth appearance. It is porous.  If you have ever been around during a delivery, you know that when a baby is born, he or she is accompanied by at least a few liters of the mother’s amniotic fluid and blood.  If a woman delivered the baby in the house, all these body fluids would drip onto the floor, and soak in. The only way to clean the floor is to get a shovel and dig up the floor. By contrast, if the woman delivers the baby in the shed, the body fluids are be absorbed by the straw, which is a lot easier to replace. So I suppose that was the logic. The obvious problem with giving birth in the shed is lack of hygiene. Over a five year period the government and public health groups succeeded in decreasing the number of women giving birth in the shed. The government was also trying to decrease the incidence of neonatal tetanus.

When I heard about the cowshed issue, it made me rethink the nativity of Jesus Christ. In Nazareth, it may have very well been the case that every woman in Biblical times gave birth in the stable. The Bible does not give the statistics to determine whether this was unusual or not.  In the West, when the nativity is told, we hear the phrase “no room at the inn” and we are conditioned to feel sorry for Mary, as though Mary was being singled out, but maybe Mary was being treated the same as every other woman of her day.

The next thing Padma told me was that most forms of contraception only became legal in 2003. Adolescent pregnancy was widespread. On a walk to the Bajar there were always a number of teenaged girls carrying babies. I learned to look for the vermilion painted at the part of her hair near the forehead, and to try to estimate the age of the woman more closely. If the vermilion was there, she was married  and the baby was hers, regardless of how young she may have looked.  I wondered how old Mary was when Jesus was born.

In Nepal every nurse receives midwife training during their undergraduate education, and every nurse in Labor and Delivery was qualified to conduct a delivery. The doctors only got involved if there were complications or if a cesarean delivery was needed. Padma was hoping to deliver some babies this summer, and if it was going to happen, she would need to build the trust of the midwives first. She would also need to be assertive and find the right time to jump in and be in charge when the time came. She would need to work with the doctors as well. Padma had a lot on her plate.  We were all hoping she would get her wish. Al told us about nearly dropping a baby when he did obstetrics; and we teased Padma about whether she would drop her first baby on the floor. They are slippery.

Nursing education

While in Patan in 2011, I video’ed the nursing lab devoted to teaching OB/GYN skills. You can find it on my YouTubeChannel, along with 20 other videos related to nursing education there.

About Joe Niemczura, RN, MS

Experienced nursing educator and problem-solver. I have fifteen years of USA nursing faculty background. Add it with fifteen more devoted to adult critical care. In Nepal, I started teaching critical care skills in 2011. I figure out what they need to know in a Nepali practice setting. Then I teach it in a culturally appropriate way so that the boots-on-the-ground people will use it. I travel outside of Kathmandu Valley as well. When the recent violence happened, I knew the cities - I had trained people in those locations. One theme of my work has been collective culture and how it manifests itself in anger. Because this was a problem I incorporated elements of "situational awareness" training from the beginning, in 2011. Global Health Nursing is not all sweetness and light; not solely milk & honey and happy moms and babies.
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6 Responses to About Maternal-Child Health in rural Nepal – link to Video

  1. Pingback: Nurse midwifery in Nepal | Nursing in Hawaii

  2. Lauren says:

    I watched the video and enjoyed it too! This summer during my internship at the mayo clinic one of my roommates was from nepal and we were able to talk about nursing here and there, very interesting.

  3. Future Nurse says:

    I watched the Witness Birth in Nepal and was immediately intrigued. The 31 year old woman who was pregnant with her sixth child and remarking that she was unsure if she would survive this birth was an eye-opener. It was disheartening to see the disappointment of the birth of a girl. I can’t imagine the intense labor (both kinds), stress and other hardships these women endure, partly because of their lower status in society. I felt grateful to have the luxury of a close hospital and other resources to health and knowledge when my children were born. I see why every RN in Nepal is also a midwife. What a difference these nurses are making in their villages. But the need must be so great….

    • please share widely among your colleagues. the rest of the video is veyr good at showing the cultural factors in village life. Now, the video was taken in Achham district, but in Palpa district where I was, if you got two km out of town, you would be in a village setting very similar. lots of scenes of village life there.

  4. Roji says:

    As a Nepalese, it is common knowledge that many births in rural Nepal (and some even in the cities) take place at home. Both of my parents, and the majority in their generation, were in fact born at home in the villages. To watch/witness a real home childbirth however, is a different thing, especially in today’s time. I dare say that the healthcare practices, prejudices against women, and social taboos witnessed in the video have remained intact for numerous generation.
    In the case of Basanti from the video, she was married at 14 and had her first child at the age of 17. Many are often wedded off when mensuration starts and often with a child within its first year. Even with 2 sons, Basanti vouches for a son at every birth since “sons are better than daughters”. She was worried when her husband in India had not called back knowing that he was upset at the birth of another girl. Many things were rather shocking to me when I watched the video. One was the lady shaking Basanti when she was in labor, the other was when they left the child on the floor uncovered for 7 minutes, and the worse was when one of the lady called the child a “rari” upon realizing that she was a girl. “Rari” in Nepali means widow but is a very derogatory word, often used to abuse women.
    It is true that men in Nepal often do not take part in child birth. Basanti’s husband was unable to help her as he was working in India but honestly I doubt her pregnancy would have been any different had he been home. Neighbors were not helpful either…being more concerned about the cameras staining Basanti’s husband reputation than her own health and life.
    Lastly, one cannot fail to neglect Basanti’s eldest daughter Sunita. As a 13 y.o, she already knows that as a female, she is a 2nd class citizen. Her “role” as a female is to do all the housework while the boys go out to play.
    I think it is commendable for the Nepali government to give an incentive of NRs 1000 (~USD12) to mothers who come to the hospital for childbirth. But when you live 5 hrs away from the nearest hospital with young children at home and no one else to look after them, home birth is the only option. As Basanti knows too well, giving new life in Nepal may often be at the cost of another.

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