Accounting for Local Culture to Promote Safer Births in Rural and Remote Nepal
Introduction: Nepal’s Safe Motherhood Initiative has been in progress since 1997, shaping its programs in a shifting political and constitutional climate that is trying to account for diversity. Recent national health plans include an emphasis on Institutional Births and development of community birthing centers. We argue that this strategy must also account for local cultural conditions, allowing women some autonomy and opportunity to participate in choices around safer birthing practices with the best possible information and support.
Methods: This paper draws on qualitative research that includes 30 interviews with health care providers, 6 focus groups with health care providers, Mother’s Groups, Female Community Health Volunteers (FCHVs) and local government policy and decision-makers, participant observation, and community based workshops. Our team consisted of local, Nepali and expatriate health care providers and social science researchers in a community based approach. Based on narrative analysis we present perspectives of health care providers in rural remote Mugu District in the Karnali region and a case study of one VDC to highlight the way provider discourse is unable to account for social obstacles to care that are both evident and exponentially more complex than a systems approach can acknowledge.
Findings: Preliminary findings indicate a mismatch between government programs that encourage institutional births in even in the most remote areas of the country, and the current capacity for some communities to utilize these strategies. There are broader community specific obstacles to increasing institutional births to improve maternal outcomes. Based on government training objectives, providers cite the need for educating women about safe birth preparedness and birthing centres through Mothers’ Groups and FCHVs, and developing a network of waiting homes for expectant mothers. On the other hand, women in some communities argue that they are in fact, making informed choices to deliver at home. Providers describe shyness and lack of women’s agency around decision making and use of finances, Women identify lack of trust in consistent 24 hour care in the centres, lack of cultural understanding and communication, lack of transport options, and fear of leaving home at night. Health care providers identify elements of community context as part of the challenge rather than part of the program.
Conclusions: We argue that a culturally responsive approach based on the local scenario is necessary to improve uptake and ensure safer births in the most remote and culturally distinct areas of Nepal’s Karnali region. In light of provider identified and locally observed challenges at the community level, we argue that in addition to emphasis on trained attendants, institutional birth, and resourced maternity waiting homes where feasible, health promotion and birth preparedness planning must be contextually informed and community engaged based on a deeper understanding of local values. Safe birth strategies must include communities to bridge the gap between ideals and the reality.