Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

At a glance: The ONWARDS insulin icodec trials

A round-up of the ONWARDS phase 3 clinical trials evaluating the novel weekly insulin icodec in people with diabetes.
ADVANCED SEARCH
Log in
Top
BMC Pregnancy and Childbirth
Published in: BMC Pregnancy and Childbirth 1/2018

Open Access 01-12-2018 | Research article

A qualitative study about the gendered experiences of motherhood and perinatal mortality in mountain villages of Nepal: implications for improving perinatal survival

Authors: Mohan Paudel, Sara Javanparast, Gouranga Dasvarma, Lareen Newman

Published in: BMC Pregnancy and Childbirth | Issue 1/2018

Login to get access

Abstract

Background

We aim to examine the gendered contexts of poor perinatal survival in the remote mountain villages of Nepal. The study setting comprised two remote mountain villages from a mid-western mountain district of Nepal that ranks lowest on the Human Development Index (0.304), and is reported as having the lowest child survival rates in the country.

Methods

The findings are taken from a larger study of perinatal survival in remote mountain villages of Nepal, conducted through a qualitative methodological approach within a framework of social constructionist and critical theoretical perspectives. Data were collected through in-depth interviews with 42 women and their families, plus a range of healthcare providers (nurses/auxiliary nurses, female health volunteers, support staff, Auxiliary Health Worker and a traditional healer) and other stakeholders from February to June, 2015. Data were analysed with a comprehensive coding process utilising the thematic analysis technique.

Results

The social construction of gender is one of the key factors influencing poor perinatal survival in the villages in this study. The key emerging themes from the qualitative data are: (1) Gendered social construct and vulnerability for poor perinatal survival: child marriages, son preference and repeated child bearing; (2) Pregnancy and childbirth in intra-familial dynamics of relationships and power; and (3) Perception of birth as a polluted event: birth in Gotha (cowshed) and giving birth alone.

Conclusions

Motherhood among women of a low social position is central to women and their babies experiencing vulnerabilities related to perinatal survival in the mountain villages. Gendered constructions along the continuum from pre-pregnancy to postnatal (girl settlement, a daughter-in-law, ritual pollution about mother and child) create challenges to ensuring perinatal survival in these villages. It is imperative that policies and programmes consider such a context to develop effective working strategies for sustained reduction of future perinatal deaths.
Appendix
Available only for authorised users
Literature
1.
Lawn JE, Blencowe H, Oza S, You D, Lee ACC, Waiswa P, et al. Every newborn: progress, priorities, and potential beyond survival. Lancet. 2014;384(9938):189–205.CrossRefPubMed
2.
WHO. Definitions and indicators in family planning maternal & child health and reproductive health used in the WHO regional office for Europe. Copenhagan: Reproductive Maternal and Child Health, European Regional Office, World Health Organization; 2000.
3.
MacDorman M, Gregory E. Fetal and perinatal mortality: United States, 2013. Natl Vital Stat Rep. 2015;64(8):1–24.
4.
Monk A, Harris K, Donnolley N, Hilder L, Humphrey M, Gordon A, et al. Perinatal deaths in Australia, 1993–2012. Perinatal deaths series no. 1. Cat. No. PER 86. Australian Institute of Health and Welfare: Canberra; 2016.
5.
Blencowe H, Cousens S, Jassir FB, Say L, Chou D, Mathers C, et al. National, regional, and worldwide estimates of stillbirth rates in 2015, with trends from 2000: a systematic analysis. Lancet Global Health. 2016;4(2):e98–e108.CrossRefPubMed
6.
UNICEF. Levels and trends in child mortality: report 2015, estimates developed by the UN inter-agency Group for Child Mortality Estimation. New York: UN IGME; 2015.
7.
8.
WHO. Global Health Observatory (GHO) data, neonatal mortality: situation and trends: World Health Organization; 2017 [cited 2017 February 06]. Available from: http://​www.​who.​int/​gho/​child_​health/​mortality/​neonatal_​text/​en/​.​
9.
Lawn JE, Blencowe H, Waiswa P, Amouzou A, Mathers C, Hogan D, et al. Stillbirths: rates, risk factors, and acceleration towards 2030. Lancet. 2016;387(10018):587–603.
10.
UNICEF and WHO. Countdown to 2015 maternal, newborn and child survival: a decade of tracking progress for maternal, newborn and child survival, the 2015 report. Geneva: World Health Organization; 2015.
11.
MOHP, New ERA, ICF International Inc. Nepal demographic and health survey 2011. Kathmandu: Ministry of Health and Population, New ERA, and ICF International, Calverton, Maryland; 2012.
12.
Lawn JE, Cousens S, Zupan J. 4 million neonatal deaths: when? Where? Why? Lancet. 2005;365(9462):891–900.CrossRefPubMed
13.
Darmstadt GL, Bhutta ZA, Cousens S, Adam T, Walker N, de Bernis L. Evidence-based, cost-effective interventions: how many newborn babies can we save? Lancet. 2005;365(9463):977–88.CrossRefPubMed
14.
Bhutta ZA, Yakoob MY, Lawn JE, Rizvi A, Friberg IK, Weissman E, et al. Stillbirths: what difference can we make and at what cost? Lancet. 2011;377(9776):1523–38.CrossRefPubMed
15.
Lawn JE, Blencowe H, Pattinson R, Cousens S, Kumar R, Ibiebele I, et al. Stillbirths: where? When? Why? How to make the data count? Lancet. 2011;377(9775):1448–63.CrossRefPubMed
16.
Bhutta ZA, Das JK, Bahl R, Lawn JE, Salam RA, Paul VK, et al. Can available interventions end preventable deaths in mothers, newborn babies, and stillbirths, and at what cost? Lancet. 2014;384(9940):347–70.CrossRefPubMed
17.
Thaddeus S, Maine D. Too far to walk: maternal mortality in context. Soc Sci Med. 1994;38(8):1091–110.CrossRefPubMed
18.
Mosley WH, Chen LC. An analytical framework for the study of child survival in developing countries. Popul Dev Rev. 1984;10:25–45.CrossRef
19.
CSDH. Closing the gap in a generation: health equity through action on the social determinants of health. Final report of the commission on social determinants of health. Geneva: World Health Organization; 2008.
20.
LSTM. Guidelines for the analysis of gender and health. Gender and Health Group, Liverpool School of Tropical Medicine and Department for International Development: United Kingdom; 1999.
21.
Pokhrel S, Snow R, Dong H, Hidayat B, Flessa S, Sauerborn R. Gender role and child health care utilization in Nepal. Health Policy. 2005;74(1):100–9.CrossRefPubMed
22.
Mahy M. Childhood mortality in the developing world: a review of evidence from the demographic and health surveys. Measure DHS, ORC Macro: Calverton; 2003.
23.
Brunson J. Confronting maternal mortality, controlling birth in Nepal: the gendered politics of receiving biomedical care at birth. Soc Sci Med. 2010;71(10):1719–27.CrossRefPubMed
24.
Simkhada B, Porter MA, van Teijlingen ER. The role of mothers-in-law in antenatal care decision-making in Nepal: a qualitative study. BMC Pregnancy Childbirth. 2010;10:34.CrossRefPubMedPubMedCentral
25.
Silverman JG, Decker MR, Cheng DM, Wirth K, Saggurti N, McCauley HL, et al. Gender-based disparities in infant and child mortality based on maternal exposure to spousal violence: the heavy burden borne by Indian girls. Archives Pedia Adolescent Med. 2011;165(1):22–7.
26.
Martines J, Paul VK, Bhutta ZA, Koblinsky M, Soucat A, Walker N, et al. Neonatal survival: a call for action. Lancet. 2005;365(9465):1189–97.CrossRefPubMed
27.
de Bernis L, Kinney MV, Stones W, ten Hoope-Bender P, Vivio D, Leisher SH, et al. Stillbirths: ending preventable deaths by 2030. Lancet. 2016;387(10019):703–16.CrossRefPubMed
28.
Mason E, McDougall L, Lawn JE, Gupta A, Claeson M, Pillay Y, et al. From evidence to action to deliver a healthy start for the next generation. Lancet. 2014;384(9941):455–67.CrossRefPubMed
29.
MOHP. National Neonatal Health Strategy. In: Child health division DoHS, Nepal. Kathmandu: Department of Health Services (Child Health Division), Ministry of Health and Population (MOHP) Nepal; 2004.
30.
MOHP. National Safe Motherhood and newborn health long-term plan, 2006–2017. In: Family health division DoHS, Nepal. Kathmandu: Family Health Division, Department of Health Services, Nepal; 2006.
31.
Ulizzi L, Zonta L. Sex differential patterns in perinatal deaths in Italy. Hum Biol. 2002;74(6):879–88.CrossRefPubMed
32.
Fuse K, Crenshaw EM. Gender imbalance in infant mortality: a cross-national study of social structure and female infanticide. Soc Sci Med. 2006;62(2):360–74.CrossRefPubMed
33.
Arnold F. Sex preference and its demographic and health implications. Int Fam Plan Perspect. 1992;18:93–101.
34.
Nie J-B. Non-medical sex-selective abortion in China: ethical and public policy issues in the context of 40 million missing females. Br Med Bull. 2011;98(1):7–20.CrossRefPubMed
35.
Shah R, Mullany LC, Darmstadt GL, Talukder RR, Rahman SM, Mannan I, et al. Determinants and pattern of care seeking for preterm newborns in a rural Bangladeshi cohort. BMC Health Serv Res. 2014;14(1):417.CrossRefPubMedPubMedCentral
36.
Rosenstock S, Katz J, Mullany LC, Khatry SK, LeClerq SC, Darmstadt GL, et al. Sex differences in neonatal mortality in Sarlahi, Nepal: the role of biology and environment. J Epidemiol Community Health. 2013;67(12):986–91.CrossRefPubMed
37.
UNFPA. Programme of action of the international conference on population development, 20th anniversary edition. United Nations Population Fund, 2014.
38.
Stenberg K, Axelson H, Sheehan P, Anderson I, Gülmezoglu AM, Temmerman M, et al. Advancing social and economic development by investing in women's and children's health: a new global investment framework. Lancet. 2014;383(9925):1333–54.CrossRefPubMed
39.
UNFPA. The state of the world population 2013: motherhood in childhood: facing the challenge of adolescent pregnancy. New York: United Nations Population Fund; 2013.
40.
Bloom SS, Wypij D, Gupta MD. Dimensions of women’s autonomy and the influence on maternal health care utilization in a north Indian city. Demography. 2001;38(1):67–78.CrossRefPubMed
41.
Kaphle S, Hancock H, Newman LA. Childbirth traditions and cultural perceptions of safety in Nepal: critical spaces to ensure the survival of mothers and newborns in remote mountain villages. Midwifery. 2013;29(10):1173–81.CrossRefPubMed
42.
Dhakal S, van Teijlingen E, Raja EA, Dhakal KB. Skilled Care at Birth among rural women in Nepal: practice and challenges. J Health Popul Nutr. 2011;29(4):371–8.CrossRefPubMedPubMedCentral
43.
Deo KK, Paudel YR, Khatri RB, Bhaskar RK, Paudel R, Mehata S, et al. Barriers to utilization of antenatal Care Services in Eastern Nepal. Front Public Health. 2015;3(197):197.PubMedPubMedCentral
44.
Paudel M, Khanal V, Acharya B, Adhikari M. Determinants of postnatal service utilization in a Western District of Nepal: community based cross sectional study. J Women’s Health Care. 2013;2(126):2167–0420.
45.
Wagle RR, Sabroe S, Nielsen BB. Socioeconomic and physical distance to the maternity hospital as predictors for place of delivery: an observation study from Nepal. BMC Pregnancy Childbirth. 2004;4(1):8.CrossRefPubMedPubMedCentral
46.
Shrestha SK, Banu B, Khanom K, Ali L, Thapa N, Stray-Pedersen B, et al. Changing trends on the place of delivery: why do Nepali women give birth at home? Reprod Health. 2012;9(1):25.CrossRefPubMedPubMedCentral
47.
Shah R, Rehfuess EA, Maskey MK, Fischer R, Bhandari PB, Delius M. Factors affecting institutional delivery in rural Chitwan district of Nepal: a community-based cross-sectional study. BMC Pregnancy Childbirth. 2015;15:27.CrossRefPubMedPubMedCentral
48.
Dahal RK. Factors influencing the choice of place of delivery among women in eastern rural Nepal. Int J Maternal Child Health. 2013;1(2):30–7.CrossRef
49.
Manandhar S, Ojha A, Manandhar D, Shrestha B, Shrestha D, Saville N, et al. Causes of stillbirths and neonatal deaths in Dhanusha district, Nepal: a verbal autopsy study. Kathmandu Univ Med J (KUMJ). 2010;8(29):62.
50.
Manandhar S, Manandhar D, Adhikari D, Shrestha J, Rai C, Rana H, et al. Analysis of health facility based perinatal verbal autopsy of electoral constituency 2 of Arghakhanchi District, Nepal. J Nepal Health Res Counc. 2015;13(29):73–7.PubMed
51.
Shrestha M, Manandhar DS, Dhakal S, Nepal N. Two year audit of perinatal mortality at Kathmandu medical college teaching hospital. Kathmandu Univ Med J (KUMJ). 2006;4(2):176–81.
52.
Khanal S, Sharma J, Gc VS, Dawson P, Houston R, Khadka N, et al. Community health workers can identify and manage possible infections in neonates and young infants: MINI--a model from Nepal. J Health Popul Nut. 2011;29(3):255–64.
53.
Dhakwa JR, Bhandari NN, Shedain PR, Khanal S, Pradhan A, Shrestha BM, et al. A report on verbal autopsy to ascertain causes of neonatal deaths in Nepal 2014. Kathmandu: Integrated Rural Health and Development Training Centre and USAID Nepal; 2014.
54.
Polit DF, Beck CT. Nursing research: generating and assessing evidence for nursing practice. 9th ed. Philadelphia: Wolters Kluwer Health, Lippincott Williams & Wilkins; 2012.
55.
Liamputtong P. Researching the vulnerable: a guide to sensitive research methods. London. Thousand Oaks, California: Sage; 2007.CrossRef
56.
NPC, UNDP. Nepal human development report 2014: beyond geography, unlocking human potential. Kathmandu: National Planning Commisssion [Nepal] and UNDP; 2014.CrossRef
57.
Ritchie J, Lewis J, Nicholls CM, Ormston R. Qualitative research practice: a guide for social science students and researchers: sage; 2003.
58.
Patton MQ. Qualitative interviewing. Qualitative research and evaluation methods. 3rd ed. Thousand Oaks, London: New Delhi Sage Publications; 2002. p. 598.
59.
Devers KJ, Frankel RM. Study design in qualitative research--2: sampling and data collection strategies. Educ Health. 2000;13(2):263.CrossRef
60.
Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77–101.CrossRef
61.
Paudel M. Socio-cultural and health care contexts of perinatal survival in Rural Mountain villages of Nepal: Flinders University 2017.
62.
NHMRC. National statement on ethical conduct in human research 2007 (updated may 2015). Canberra: The National Health and Medical Research Council, the Australian Research Council and the Australian Vice-Chancellors’ Committee. Commonwealth of Australia, Canberra; 2015. p. 95.
63.
MOHP. Nepal population report 2011. In: Division P. Kathmandu: Population Division, Ministry of Health and Population (MOHP); 2011.
64.
Karki S. A study on dowry related violence in Nepal. Kathmandu; 2014.
65.
MOHP. National Policy on skilled birth attendants (Supplementatry to safe motherhood policy 1998). In: family health division DoHS, Nepal, editor. Kathmandu: Family Health Division, Department of Health Services, Nepal; 2006.
66.
MOHP. Mother’s protection program-implementation guideline, 2008 (second amendment 2013). In: Department of Health Services N, editor. Kathmandu: Family Health Division, Department of Health Services; 2013.
67.
Maharjan RK, Karki KB, Shakya TM, Aryal B. Child marriage in Nepal: a research report. Kathmandu: Plan Nepal, Save the Children and World Visioin International; 2012.
68.
Sharma V, Katz J, Mullany LC, Khatry SK, LeClerq SC, Shrestha SR, et al. Young maternal age and the risk of neonatal mortality in rural Nepal. Arch Pedia Adol Med. 2008;162(9):828–35.CrossRef
69.
Almond D, Edlund L, Milligan K. Son preference and the persistence of culture: evidence from south and east Asian immigrants to Canada. Popul Dev Rev. 2013;39(1):75–95.CrossRef
70.
Arnold F, Choe MK, Roy TK. Son preference, the family-building process and child mortality in India. Popul Stud. 1998;52(3):301–15.CrossRef
71.
Barot S. A problem-and-solution mismatch: son preference and sex-selective abortion bans. Gutmacher Policy Rev. 2012;12(2):18(5).
72.
Brunson J. Son preference in the context of fertility decline: limits to new constructions of gender and kinship in Nepal. Stud Fam Plan. 2010;41(2):89–98.CrossRef
73.
Pande R, Malhotra A, Mathur S, Mehta M, Malhotra A, Lycette MA, et al. Son preference and daughter neglect in India: what happens to living girls? International Center for Research on Women, 2006.
74.
Riessman CK. Locating the outsider within: studying childless women in India. Reflections. 1995;1(3):5–14.
75.
Patel T. Fertility behaviour: population and society in a Rajasthan village. 2nd ed. New Delhi: Oxford University Press, Delhi; 2006.
76.
Widge A. Sociocultural attitudes towards infertility and assisted reproduction in India. Geneva: Switzerland World Health Organization; 2002.
77.
Ware H. Women, demography and development (demography teaching notes; 3). Canberra: Development Studies Centre, Australian National University; 1981.
78.
Lowell A, Kildea S, Liddle M, Cox B, Paterson B. Supporting aboriginal knowledge and practice in health care: lessons from a qualitative evaluation of the strong women, strong babies, strong culture program. BMC preg childbirth. 2015;15(1):19.CrossRef
79.
Government of Nunavut. Nunavut maternal and newborn health care strategy 2009–2014. Nunavut: Department of Health and Social Services; 2009. ISBN 978-1-55325-169-9
80.
Hussein J, McCaw-Binns A, Weber R. Maternal and perinatal health in developing countries. Scotland: CABI; 2012.CrossRef
81.
WHO. Fatherhood and health outcomes in Europe. Copenhagen: World Health Organization, Regional Office for Europe; 2007.
82.
Piet-Pelon NJ, Rob U, Khan M. Men in Bangladesh, India, and Pakistan: reproductive health issues: Hindustan publishing corporation (India); 1999.
83.
Bandyopadhyay M. Impact of ritual pollution on lactation and breastfeeding practices in rural West Bengal. India Int Breastfeeding J. 2009;4:2.CrossRef
84.
Winch PJ, Alam MA, Akther A, Afroz D, Ali NA, Ellis AA, et al. Local understandings of vulnerability and protection during the neonatal period in Sylhet District, Bangladesh: a qualitative study. Lancet. 2005;366(9484):478–85.CrossRefPubMed
85.
Tarafder T, Sultan P. Reproductive health beliefs and their consequences: a case study on rural indigenous women in Bangladesh. Australasian J Reg Stud. 2014;20(2):351.
86.
Darmstadt GL, Syed U, Patel Z, Kabir N. Review of domiciliary newborn-care practices in Bangladesh. J Health Popul Nutr. 2006;24(4):380–93.PubMedPubMedCentral
87.
Sharma S, van Teijlingen E, Hundley V, Angell C, Simkhada P. Dirty and 40 days in the wilderness: eliciting childbirth and postnatal cultural practices and beliefs in Nepal. BMC Preg Childbirth. 2016;16(1):147.CrossRef
88.
Paudel M, Javanparast S, Dasvarma G, Newman L. Religio-cultural factors contributing to perinatal mortality and morbidity in mountain villages of Nepal: implications for future healthcare provision. PLoS One. 2018;13(3):e0194328. eCrossRefPubMedPubMedCentral
89.
Dickson KE, Kinney MV, Moxon SG, Ashton J, Zaka N, Simen-Kapeu A, et al. Scaling up quality care for mothers and newborns around the time of birth: an overview of methods and analyses of intervention-specific bottlenecks and solutions. BMC Preg Childbirth. 2015;15(2):1–19.CrossRef
90.
Bhutta ZA, Darmstadt GL, Hasan BS, Haws RA. Community-based interventions for improving perinatal and neonatal health outcomes in developing countries: a review of the evidence. Pediatrics. 2005;115(Supplement 2):519–617.CrossRefPubMed
91.
MOHP. Community based newborn care program (CB-NCP): program management module (first Ammendment). In: Child health division DoHS, Nepal. Kathmandu: Nepal: Department of Health Service, Ministry of Health and Population, Nepal; 2010. p. 100.
92.
Irwin A, Scali E, Irwin A, Scali E. Action on the social determinants of health: learning from previous experiences. Social determinants of health discussion paper 1 (debates). Geneva: World Health Organization; 2010.
93.
Human Rights Watch. Our time to sing and play child marriage in Nepal. Kathmandu: Human Rights Watch; 2016.
94.
Manandhar DS, Osrin D, Shrestha BP, Mesko N, Morrison J, Tumbahangphe KM, et al. Effect of a participatory intervention with women's groups on birth outcomes in Nepal: cluster-randomised controlled trial. Lancet. 2004;364(9438):970–9.CrossRefPubMed
95.
O'Rourke K, Howard-Grabman L, Seoane G. Impact of community organization of women on perinatal outcomes in rural Bolivia. Revista Panamericana De Salud Pública =. Pan Am J Public Health. 1998;3(1):9–14.CrossRef
96.
Persson LA, Nga NT, Malqvist M, Thi Phuong Hoa D, Eriksson L, Wallin L, et al. Effect of facilitation of local maternal-and-newborn stakeholder groups on neonatal mortality: cluster-randomized controlled trial. PLoS Med. 2013;10(5):e1001445.CrossRefPubMedPubMedCentral
97.
DoHS. Safe abortion service program implementation guideline 2016. In: Family health division DoHS, Nepal. Kathmandu: Nepal: Department of Health Services, Family Health Division, Ministry of Health and Populaiton, Nepal; 2016.
98.
WHO. Every newborn: an action plan to end preventable deaths. Geneva: World Health Organization; 2014.
Metadata
Title
A qualitative study about the gendered experiences of motherhood and perinatal mortality in mountain villages of Nepal: implications for improving perinatal survival
Authors
Mohan Paudel
Sara Javanparast
Gouranga Dasvarma
Lareen Newman
Publication date
01-12-2018
Publisher
BioMed Central
Published in
BMC Pregnancy and Childbirth / Issue 1/2018
Electronic ISSN: 1471-2393
DOI
https://doi.org/10.1186/s12884-018-1776-3

Other articles of this Issue 1/2018

BMC Pregnancy and Childbirth 1/2018 Go to the issue

Research article

Iodine deficiency in pregnant women after the adoption of the new provincial standard for salt iodization in Zhejiang Province, China

Research article

Maternal sedentary behavior during pre-pregnancy and early pregnancy and mean offspring birth size: a cohort study

Research article

Childbirth fear and related factors among pregnant and postpartum women in Malawi

Research article

Spatial distribution of antenatal care utilization and associated factors in Ethiopia: evidence from Ethiopian demographic health surveys

Research article

Urinary iodine concentration and thyroid volume of pregnant women attending antenatal care in two selected hospitals in Ashanti Region, Ghana: a comparative cross-sectional study

Research article

Association of intimate partner violence during pregnancy, prenatal depression, and adverse birth outcomes in Wuhan, China