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 hospital told me not to work, but what can be done?"
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 capitol 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.
Her husband stayed seated as Lalu grunted and panted her way through her chores.
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."