Mobilizing for safe motherhood in Nepal

16 World Health • Slst Year, No. 1, Jonuory-February 1998 Mobilizing for safe motherhood in Nepal Martha Levitt & Nancy Russell Thanks to the efforts of several nongovemmental organizations, many communities in Nepal are now involved in promoting the messages of Safe Motherhood. Strong religious and cultural beliefs and practices regarding reproduction are deeply embed- ded in the traditional societies of Nepal. Family members, particularly husbands and mothers-in-law, enforce and perpetuate these behav- ioural norms. Unfortunately, some of the traditions are harmful and put women and their newborn babies at risk of lifelong disability or death. Many nongovernmental organiza- tions and government agencies have been working to eliminate life- threatening practices, while encour- aging or introducing life-saving ones. Reaching women and their fami- lies with safe motherhood messages - and ensuring that these messages are relevant to their lives - is ex- tremely difficult. The fact that only 37% of the households have a radio and 6% have television restricts the awareness-creating potential of the broadcast media. Even where radios exist, the messages may be hard to grasp. With less than one in four women literate, those with access to health information through newspa- pers, brochures or posters are a minority. Some local beliefs also limit access to health care. In Nepal, pregnancy and delivery are viewed as natural conditions requiring no health care intervention. Childbearing women and their families only seek care when a condition becomes debilitating or life-threatening. More than 92% of the deliveries are at home, mostly assisted by untrained relatives or traditional birth attendants. As birth is considered to be polluting, birth attendants are very careful to wash their hands after assisting with a birth, but not before. Traditionally, childbirth takes place in a cowshed and dirty materials are used for delivery and cord care. In obstetric emergencies, the first course of action is generally to call in a faith healer who performs exorcisms and healing rituals. Only when that fails may the family decide to call on a health worker. Even when hospital services are used, few have facilities which can manage obstetric emergencies re- quiring surgery or blood transfu- sions. Consequently, Nepal is one of the three countries in the world where women's life expectancy is less than men 's. Low female life expectancy is closely correlated to a high maternal mortality ratio. There are an estimated 539 maternal deaths for every 100 OOO live births, which means that there is one maternal death every two hours in Nepal. Because of the lack of communi- cation technology, knowledge is passed on almost entirely by word of mouth. The result is that decisions may be based on local rumour and misinformation. To make matters more difficult, even when informa- tion is available, women of child- bearing age have little or no power to take action, especially regarding their own reproductive health. Nepali women have not traditionally partici- pated in community affairs outside the home. A Nepalese elephant, bearing health messages leads the "Safe Motherhood March" on International Women 's Day. Photo WHO/CEDPA World Health • SlstYear, No. 1, Janumy-February 1998 Celebrating International Women's Day Given this context, massive commu- nity mobilization was difficult to imagine. Yet on International Women's Day, 8 March 1996, more than 50 OOO women from 41 of the 75 districts of Nepal took part in calling for an improvement in mater- nal health. With the help of 20 non- governmental organizations and government agencies, a well- organized demonstration took place. A parade of women in brightly coloured saris marched down roads and dirt trails, across rice fields, over bridges - all the while chanting and carrying signs calling for safer moth- erhood. What had created this energy? In 1993, the Nepali Government had approved a national safe motherhood policy. Yet three years later a national safe motherhood programme had still not been launched. The development community and the Government itself were frustrated and confused by this inertia, but did not know how to get started. They nevertheless shared the struggle for common goals such as providing safe mother- hood supplies, information and educational materials to women and their husbands and families. The idea of mobilizing commu- nity-based organizations was the inspiration of a few individuals. Their goal was to encourage grass- roots groups to launch safe mother- hood awareness campaigns as part of their work with families and commu- nities throughout the country. They helped to form the original coalition of groups working at the grass roots, which comprised the Centre for Development and Population Activities, Save the Children Alliance, Maternal and Child Health Limited, Johns Hopkins University Population Services, United Mission to Nepal, Nepal Red Cross, Mothers' Club and the Ministry of Health. Other groups were invited to become partners in the planning and achievement of that first event on International Women's Day in 1996. The coalition chose the theme of "National Clean Delivery Day". In response, local political leaders and government officials became advo- cates for "clean delivery" and the Prime Minister's wife, herself a new mother, became the coalition's hon- orary chairperson. On the day, in addition to the demonstration, sev- eral organizations launched new services offering disposable "Clean Home Delivery Kits" and maternity care. Thousands of kits, posters, and brochures were made available. Articles were published in newspa- pers and a press release was sent out to national and local papers. The organizers had developed a district level guide containing stan- dardized messages relating to clean delivery which was disseminated nationwide. In response, communi- ties organized innovative participa- tory activities in local languages that were both relevant and entertaining to local people. Local women rallied, Student nurses transmit the message of making motherhood safer. Photo WHO/ CEDPA 17 sang songs, enacted dramas, played games, gave speeches, displayed posters, handed out brochures, held discussions, and demonstrated the correct use of the clean home deliv- ery kit. Junior Red Cross volunteers managed the logistics, and students held bicycle races wearing banners with safe motherhood messages. In one remote village, a tug of war was held to "pull for safe motherhood". In others, villagers held other com- petitions and sporting events. No two events were the same. Each was a unique expression of local creativity. However, although each event was distinctive, all fo- cused on the simple messages about safe, clean delivery, highlighting the "three cleans" - clean hands, clean surface and clean blade (for cutting the cord). As a result of this collaborative effort, "The Safe Motherhood at the Community and Family Level Support Network" was formed. The Network now has a membership of 61 organizations, and several nation- wide awareness-creating events have taken place. The national Safe Motherhood programme has been launched, two major workshops have been held, and in 1997, International Women's Day in Nepal used the slogan "Safe Motherhood - It is a family responsibility". Today, safe motherhood mes- sages are estimated to have reached 8-9 million women and men across the country. Some people have had information through print and broad- cast media, while hundreds of thou- sands have been mobilized in villages and towns across the coun- try during national holidays and traditional Nepali festivals. Each event informs families and commu- nities about what they can do to make motherhood safer. • Or Martha Levitt is Pro;ect Director, Redd Barna, P.O. Box 3394, Kathmandu, Nepal, and Nancy Russell is Resident Adviser to the Centre For Development and Population Activities {CEDPAJ, Nepal Field Office, GPO 8975, EPC 5316, Bhatbhateni, Kathmandu, Nepal.