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Infant and maternal health care in Nepal
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Infant and maternal health care in Nepal

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Content
 

   
 

 

 
INFANT
 AND
 MATERNAL
 HEALTH
 CARE
 IN
 NEPAL
 

 

 

 
by
 

 

 

 
Gabriella
 Perez-­‐Silva
 

 

 

 

 

 

 

 

 

 

 

 

 
A
 Thesis
 Presented
 to
 the
 
FACULTY
 OF
 THE
 USC
 GRADUATE
 SCHOOL
 
UNIVERSITY
 OF
 SOUTHERN
 CALIFORNIA
 
In
 Partial
 Fulfillment
 of
 the
 
Requirements
 for
 the
 Degree
 
MASTER
 OF
 ARTS
 
(STRATEGIC
 PUBLIC
 RELATIONS)
 

 

 

 
August
 2012
 

 

 

 

 

 

 

 

   
   
 
Copyright
 2012
   
   
   
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Gabriella
 Perez-­‐Silva

 

 
ii
 

 
Dedication
 
After
 reaching
 the
 summit
 of
 Mt.
 Everest,
 Edmund
 Hillary
 remarked,
 “It
 is
 not
 
the
 mountain
 we
 conquer,
 but
 ourselves
1
.”
 
 This
 thesis
 is
 dedicated
 to
 the
 people
 of
 
Nepal.
 
 My
 experiences
 in
 Nepal
 not
 only
 contributed
 greatly
 to
 my
 thesis,
 but
 also
 
opened
 my
 own
 mind
 to
 the
 splendor
 of
 life.
 
 Their
 unfailing
 ability
 to
 find
 the
 
beauty
 in
 even
 the
 deepest
 sorrows
 is
 inspirational
 and
 I
 hope
 that
 I
 have
 done
 their
 
stories
 and
 their
 lives
 justice.
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
1

 “Edmund
 Hillary
 Quotes.”
 Thinkexist.com.
 
http://thinkexist.com/quotes/edmund_hillary/
 

 

 
iii
 

 
Acknowledgements
 
I
 did
 not
 take
 the
 traditional
 approach
 to
 writing
 my
 thesis,
 and
 it
 was
 only
 
through
 the
 support
 and
 guidance
 of
 my
 family
 and
 my
 committee
 chairperson
 that
 
I
 was
 able
 to
 complete
 it.
 
 Thank
 you
 to
 Mom,
 Dad
 and
 Ali
 for
 giving
 me
 the
 courage
 
and
 the
 opportunity
 to
 travel
 to
 Nepal
 and
 experience
 first-­‐hand
 what
 I
 wrote
 about.
 
 
And
 thank
 you
 to
 Mom
 and
 Dad
 for
 the
 wonderful
 work
 you
 are
 doing
 in
 Nepal,
 and
 
the
 love
 and
 dedication
 that
 you
 continually
 give
 to
 others.
 
 You
 inspire
 everyone
 
around
 you.
 
 And
 to
 Jennifer
 Floto,
 my
 chairperson
 and
 mentor,
 thank
 you
 for
 your
 
encouragement
 and
 guidance
 throughout
 this
 entire
 process.
 
 Your
 belief
 in
 my
 
thesis
 is
 what
 enabled
 me
 to
 complete
 it,
 even
 though
 it
 demanded
 extra
 attention.
 
 I
 
would
 also
 like
 to
 thank
 my
 committee
 members,
 Laura
 Min
 Jackson
 and
 Jay
 Wang
 
for
 their
 feedback
 and
 opinions.
 
 Finally,
 I
 must
 thank
 my
 interview
 sources
 for
 their
 
insight
 and
 expertise.
 
 Their
 knowledge
 of
 the
 subject
 added
 tremendously
 to
 the
 
credibility
 of
 this
 thesis.
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
iv
 

 
Table
 of
 Contents
 

 
Dedication
   
   
   
   
   
   
   
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ii
 
 
Acknowledgements
   
   
   
   
   
   
   
   
   
 
 
 
 
 
 
 
 
 iii
 
List
 of
 Tables
 
   
   
   
   
   
   
   
   
   
 
 
 
 
 
 
 
 
 
 vi
 
List
 of
 Figures
   
   
   
   
   
   
   
   
   
 
 
 
 
 
 
 
 vii
 
Relevant
 Abbreviations
   
   
   
   
   
   
   
   
 
 
 
 
 
 
 viii
 
Abstract
   
   
   
   
   
   
   
   
   
   
 
 
 
 
 
 
 
 
 
 ix
 
Introduction
   
   
   
   
   
   
   
   
   
   
 
 
 
 
 
 
 
 
 
 
 1
 
Chapter
 One:
 Nepal’s
 Geography
   
   
   
   
   
   
   
 
 
 
 
 
 
 
 
 
 
 3
 
Chapter
 Two:
 The
 Nepali
 People
   
   
   
   
   
   
   
 
 
 
 
 
 
 
 
 
 
 5
 
Chapter
 Three:
 Changing
 Landscape
 and
 Development
   
   
   
   
 
 
 
 
 
 
 
 
 
 
 9
 
Chapter
 Four:
 Women
 in
 Nepal
   
   
   
   
   
   
   
 
 
 
 
 
 
 
 12
 
Chapter
 Five:
 Maternal
 Health
 and
 Mortality
 in
 Nepal
   
   
   
   
 
 
 
 
 
 
 
 16
 
Chapter
 Six:
 Causes
 of
 Maternal
 Deaths
   
   
   
   
   
   
 
 
 
 
 
 
 
 19
 
Chapter
 Seven:
 Timing
 of
 Pregnancy-­‐Related
 Deaths
   
   
   
   
 
 
 
 
 
 
 
 21
 
Chapter
 Eight:
 Place
 of
 Pregnancy-­‐Related
 Deaths
   
   
   
   
 
 
 
 
 
 
 
 23
 
Chapter
 Nine:
 Hospital
 or
 Health
 Care
 Facility
 Deaths
   
   
   
   
 
 
 
 
 
 
 
 25
 
Chapter
 Ten:
 Lamjung
 and
 Tanahun
 Valley
 Births
 
   
   
   
   
 
 
 
 
 
 
 
 26
 
Chapter
 Eleven:
 Mental
 Health
   
   
   
   
   
   
   
 
 
 
 
 
 
 
 30
 
Chapter
 Twelve:
 Health
 Care
 for
 Immigrants
   
   
   
   
   
 
 
 
 
 
 
 
 34
 
Chapter
 Thirteen:
 Infant
 Mortality
 
   
   
   
   
   
   
 
 
 
 
 
 
 
 36
 

 

 
v
 

 
Chapter
 Fourteen:
 Under-­‐5
 Mortality
 in
 Nepal
   
   
   
   
   
 
 
 
 
 
 
 
 39
 
Chapter
 Fifteen:
 Government
 Aid
 and
 Immunization
   
   
   
   
 
 
 
 
 
 
 
 42
 
Chapter
 Sixteen:
 Clean
 Home
 Delivery
 Kits
   
   
   
   
   
 
 
 
 
 
 
 
 44
 
 
Chapter
 Seventeen:
 International
 Efforts
   
   
   
   
   
   
 
 
 
 
 
 
 
 48
 
 
Conclusions
   
   
   
   
   
   
   
   
   
   
 
 
 
 
 
 
 
 51
 
Strategic
 Planning
 Model:
 Preparing
 A
 Plan
 for
 Nepal’s
 Fight
 for
 Maternal/Infant
 
Care
   
   
   
   
   
   
   
   
   
   
 
 
 
 
 
 
 
 54
 

   
   
   
   
   
 
 
 
 
 
 
 
   
   
   
   
   
 
 
 
 
 
 
 
 
 
Bibliography
 
   
   
   
   
   
   
   
   
   
 
 
 
 
 
 
 
 60
 
Appendices
   
   
   
   
   
   
   
   
   
   
 
 
 
 
 
 
 
 
 
Appendix
 A:
 Key
 Findings
 from
 Anonymous
 Online
 Survey
 Conducted
 by
 the
 
Author
 
   
   
   
   
   
   
   
   
 
 
 
 
 
 
 
 65
 
Appendix
 B:
 Interview
 with
 Dr.
 Martha
 Carlough
 
   
   
   
 
 
 
 
 
 
 
 66
 
Appendix
 C:
 Interview
 with
 Katie
 Lillie
   
   
   
   
   
 
 
 
 
 
 
 
 68
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
vi
 

 
List
 of
 Tables
 

 
Table
 1:
 Levels
 of
 all-­‐cause
 mortality
 among
 women
 of
 reproductive
 age
 
 
2008-­‐2009
   
   
   
   
   
   
 
 
 
 
 
 
 
 16
 
 
 
 
 
 
 
 
 
 
 

 
Table
 2:
 Comparison
 of
 babies
 born
 to
 miscarriages
 in
 the
 Tanahun
 and
 Lamjung
 
Valley
 districts,
 2011
 
   
   
   
   
   
   
   
 
 
 
 
 
 
 
 25
 

 
Table
 3:
 Mortality
 rate
 in
 children
 under
 5
 by
 WHO
 region
 
 
   
   
   
 
 
 
 
 
 
 
 38
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
vii
 

 
List
 of
 Figures
 

 
Figure
 1:
 Causes
 of
 Maternal
 Deaths
 in
 rural
 Nepal,
 2008-­‐2009
 
 
   
   
 
 
 
 
 
 
 
 19
 
Figure
 2:
 Place
 of
 Pregnancy
 Related
 Deaths
 in
 rural
 Nepal,
 2008-­‐2009
 
   
 
 
 
 
 
 
 
 24
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
viii
 

 
Relevant
 Abbreviations
 

 
ARIs
  Acute
 Respiratory
 Infections
 
BCG
  Bacillus
 Calmette-­‐Guéin
 
DoHS
  Department
 of
 Health
 Services
 
EOC
  Emergency
 Obstetric
 Care
 
FHD
  Family
 Health
 Division
 
GNI
 per
 
capita
 
Gross
 National
 Income
 divided
 by
 mid-­‐year
 population
 
Hib
  Haemophilus
 type
 B
 pneumonia
 
IMM
  Infant
 and
 Maternal
 Morbidity
 
IMR
  Infant
 Mortality
 Rate
 
MDHP
  Maternal
 and
 Child
 Health
 Products,
 Ltd.
 
MDR
  Maternal
 Death
 Reviews
 
MMM
  Maternal
 Mortality
 and
 Morbidity
 
MMMS
  NEPAL:
 Maternal
 Mortality
 and
 Morbidity
 Study
 
MMR
  Maternal
 Mortality
 Ratio
 
MMR
 
Vaccine
 
Measles,
 Mumps
 and
 Rubella
 Vaccine
 
NDHS
  Nepal
 Demographic
 and
 Health
 Survey
 
NGO
  Non-­‐Governmental
 Organization
 
 
ORT
  Oral
 Rehydration
 Therapy
 
ORT
  Oral
 Rehydration
 Therapy
 
PATH
  Program
 for
 Appropriate
 Technology
 in
 Health
 
RHP
  Rupakot
 Health
 Post
 
TDaP
 
  Tuberculosis,
 Diphtheria
 and
 Pertussis
 Vaccine
 
UCPN(M)
  The
 Unified
 Communist
 Party
 of
 Nepal
 (Maoist)
 
UNMDGs
  United
 Nations
 Millennium
 Development
 Goals
 
WHO
  World
 Health
 Organization
 
WRA
  Women
 of
 Reproductive
 Age
 

 

 

 

 

 
ix
 

 
Abstract
 
This
 paper
 examines
 the
 past
 and
 present
 future
 of
 Nepal,
 its
 culture
 and
 its
 
health
 care.
 
 Specifically,
 it
 addresses
 some
 of
 the
 primary
 issues
 surrounding
 infant
 
and
 maternal
 health
 care
 in
 the
 rural
 villages
 in
 the
 foothills
 of
 the
 Himalayan
 
Mountains.
 
 The
 purpose
 of
 this
 analysis
 is
 to
 not
 only
 understand
 the
 main
 causes
 
of
 death
 and
 the
 medical
 and
 cultural
 cures
 for
 the
 causes
 of
 death,
 but
 also
 to
 
understand
 the
 reasons
 that
 these
 cures
 are
 not
 being
 employed.
 
 Another
 aim
 is
 to
 
study
 how
 communication
 and
 public
 relations
 can
 increase
 awareness
 of
 diseases
 
and
 disease
 prevention
 in
 rural
 areas,
 and
 to
 explore
 the
 obstacles
 that
 language
 
and
 cultural
 differences
 can
 create
 when
 introducing
 Western
 concepts
 into
 these
 
areas.
 
 The
 key
 issues
 addressed
 in
 this
 paper
 include
 the
 geographical
 origins
 of
 
Nepal
 and
 how
 the
 topography
 has
 contributed
 to
 the
 cultural
 composition
 of
 the
 
country,
 the
 main
 causes
 of
 infant
 and
 maternal
 deaths,
 and
 the
 possible
 solutions
 
for
 preventable
 deaths.
 
 The
 results
 prove
 that
 while
 most
 people
 in
 the
 United
 
States
 are
 unfamiliar
 with
 the
 problems
 in
 Nepal,
 they
 are
 sympathetic
 to
 charitable
 
causes
 in
 developing
 countries,
 and
 are
 will
 to
 donate
 to
 non-­‐governmental
 
organizations.
 
 The
 principal
 conclusion
 is
 that
 despite
 the
 fact
 that
 many
 Nepalis
 
practice
 ancient
 customs,
 the
 younger
 generations
 are
 open
 to
 Western
 ideas,
 and
 
through
 proper
 communication,
 are
 likely
 to
 implement
 these
 new
 customs
 into
 
their
 daily
 lives.

 

 

 

 
1
 

 
Introduction
 
Infant
 and
 Maternal
 Mortality
 is
 a
 global
 problem.
 
 The
 under-­‐5
 mortality
 rate
 
in
 2008
 was
 65
 per
 1,000
 worldwide,
 and
 according
 to
 the
 World
 Health
 
Organization,
 358,000
 women
 died
 from
 complications
 suffered
 during
 pregnancy
 
and
 childbirth
 in
 2008,
2

 with
 the
 majority
 of
 the
 deaths
 occurring
 in
 developing
 
countries.
 
 It
 is
 particularly
 worrisome
 in
 the
 country
 of
 Nepal.
 
 
 However,
 in
 Nepal,
 
the
 problem
 can
 be
 addressed
 through
 simple
 measures,
 such
 as
 providing
 proper
 
vaccines
 and
 recognizing
 symptoms
 of
 distress.
 
 Through
 research,
 various
 
governmental
 and
 non-­‐profit
 organizations
 have
 proven
 that
 although
 many
 
improvements
 have
 been
 made
 around
 the
 world,
 and
 in
 Nepal,
 there
 is
 still
 a
 
significant
 amount
 of
 work
 to
 be
 done
 to
 reduce
 the
 mortality
 rate
 of
 women
 and
 
children
 in
 developing
 countries.
 
 
 
The
 author
 was
 drawn
 to
 this
 cause
 through
 her
 parents’
 involvement
 in
 
medical
 missions
 in
 Nepal.
 
 Together
 with
 a
 local
 Nepali
 man,
 Nabaraj
 Basaula,
 they
 
founded
 Avasar
 Nepal,
 a
 non-­‐governmental
 organization
 based
 in
 the
 Lamjung
 
Valley,
 aimed
 at
 bettering
 the
 lives
 of
 those
 living
 in
 rural
 Nepal
 through
 better
 
health
 care
 and
 education.
 
 Their
 travels
 to
 Nepal
 solidified
 their
 desire
 to
 help.
 
 Dr.
 
Rene
 Perez-­‐Silva,
 an
 internist,
 and
 Katherine
 Perez-­‐Silva,
 R.N.,
 first
 visited
 as
 part
 of
 a
 
medical
 mission,
 but
 realized
 the
 urgent
 need
 for
 attention.
 
 The
 author
 accompanied
 
them
 to
 Nepal
 in
 April,
 2012
 to
 further
 her
 research.
 
 Through
 this
 thesis,
 the
 author
 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
2

 
 “Maternal
 deaths
 worldwide
 drop
 by
 third.”
 15
 September
 2010.
 WHO.
 
http://www.who.int/mediacentre/news/releases/2010/maternal_mortality_
20100915/en/index.html
 

 

 
2
 

 
hopes
 to
 bring
 light
 to
 the
 many
 issues
 in
 Nepal
 and
 offer
 an
 insight
 into
 the
 major
 
problems
 with
 infant
 and
 maternal
 health
 care
 in
 an
 attempt
 to
 begin
 the
 process
 of
 
saving
 the
 lives
 of
 millions
 of
 women
 and
 children.
 
 After
 conducting
 her
 own
 
research,
 the
 author
 found
 that
 only
 35
 percent
 of
 respondents
 to
 her
 survey
 knew
 
the
 geographical
 location
 of
 Nepal.
 
 This
 will
 likely
 prove
 to
 be
 an
 obstacle
 when
 
promoting
 the
 cause.
 
The
 author
 would
 like
 to
 thank
 all
 of
 those
 who
 contributed
 to
 this
 thesis.
 
 
There
 were
 many
 people
 here
 and
 in
 Nepal
 who
 helped
 a
 great
 deal
 by
 providing
 
their
 insight,
 knowledge,
 experience
 and
 opinions.
 
 Mr.
 Basaula
 provided
 many
 
statistics,
 since
 the
 author
 was
 unable
 to
 collect
 them
 herself.
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
3
 

 
Chapter
 One:
 Nepal’s
 Geography
 
To
 understand
 the
 sociological
 and
 economic
 position
 of
 Nepal,
 one
 must
 first
 
understand
 the
 role
 geography
 plays
 in
 its
 medical
 plight.
 
 Nepal
 is
 located
 at
 the
 
base
 of
 the
 Himalayas,
 which
 were
 formed
 approximately
 70
 million
 years
 ago
 as
 the
 
Indian
 subcontinent
 slowly
 collided
 with
 Central
 Asia.
 
 About
 10
 million
 years
 ago,
 
more
 movement
 created
 the
 middle
 hills—a
 “confusion
 of
 interrupted
 ridges
 and
 
spurs,
 which
 in
 Nepal
 still
 form
 the
 cultural
 and
 political
 heart
 of
 the
 country”
3
.
 
 Over
 
the
 next
 several
 hundreds
 of
 thousands
 of
 years,
 the
 peaks
 continued
 to
 rise
 and
 the
 
land
 continued
 to
 shift.
 
 Even
 today,
 the
 Himalayas
 are
 still
 climbing
 at
 a
 rate
 of
 about
 
1
 centimeter
 per
 year
4
.
 

  The
 rise
 of
 the
 Mahabharats
 (Southern
 Hills)
 and
 the
 Siwaliks
 (Middle
 Hills)
 
blocked
 some
 of
 the
 rivers
 flowing
 south
 towards
 the
 Ganges,
 forming
 lakes
 in
 the
 
valleys
 between
 the
 ranges,
 including
 the
 Kathmandu
 Valley.
 
 
 Prominent
 among
 
them
 was
 Kathmandu
 Lake.
 There
 are
 many
 mythical
 accounts
 of
 when
 and
 how
 the
 
Kathmandu
 Lake
 dried
 up,
 however,
 the
 one
 certainty
 is
 that
 by
 the
 time
 all
 the
 
water
 had
 evaporated
 100,000
 years
 ago,
 inhabitants
 had
 already
 settled
 on
 its
 
shores.
 
The
 strong
 tectonics
 of
 the
 land
 had
 more
 substantial
 effects.
 
 As
 the
 
Himalayas
 rose,
 they
 pushed
 the
 rivers
 farther
 south
 creating
 deep
 gorges.
 
 Here,
 
Nepal’s
 three
 main
 rivers
 flow:
 The
 Karnali,
 the
 Gangaki
 and
 the
 Kosi.
 
 As
 the
 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
3

 Whelpton,
 John.
 A
 History
 of
 Nepal.
 Cambridge
 University
 Press.
 Page
 6.
 
4

 Whelpton,
 John.
 A
 History
 of
 Nepal.
 Cambridge
 University
 Press.
 Page
 6.
 

 

 

 
4
 

 
mountains
 are
 eroded,
 the
 rivers
 carry
 the
 rich
 topsoil
 and
 deposit
 it
 to
 the
 Ganges
 
plain.
 
 The
 10-­‐
 to
 30-­‐mile
 strip
 of
 plain,
 called
 Tarnai,
 is
 where
 most
 of
 the
 food
 is
 
grown,
 and
 almost
 half
 of
 the
 population
 resides.
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
5
 

 
Chapter
 Two:
 The
 Nepali
 People
 
In
 Nepal,
 the
 rich
 and
 rugged
 terrain
 has
 preserved
 the
 deep
 cultural
 
differences.
 
 One’s
 ethnic
 identity,
 often
 influenced
 by
 one’s
 geographic
 location,
 
determines
 one’s
 social
 position.
 
 It
 is
 important
 to
 note
 that
 the
 Nepali
 word
 for
 an
 
ethnic
 group,
 jat,
 is
 also
 the
 word
 for
 “caste.”
 
 From
 early
 on,
 Nepal
 has
 been
 the
 
meeting
 point
 for
 several
 different
 cultures.
 
 
 
According
 to
 Bandana
 Rai,
 author
 of
 Gorkhas:
 The
 Warrior
 Race,
 the
 renowned
 
Political
 Scientists
 Joshi
 and
 Rose
 generally
 sort
 the
 Nepali
 population
 into
 three
 
groups:
 the
 Indo-­‐Nepali,
 the
 Tibeto-­‐Nepali,
 and
 the
 indigenous
 Nepali.
 
 For
 the
 first
 
two
 groups,
 the
 geographical
 location
 strongly
 influenced
 the
 ethnic
 make-­‐up
 of
 the
 
people.
5

 
 The
 Indo-­‐Nepalis
 primarily
 inhabit
 the
 lower
 hills,
 while
 the
 Tibeto-­‐Nepalis
 
are
 located
 in
 the
 higher
 hills
 and
 mountains.
 
 One’s
 appearance
 often
 signifies
 one’s
 
ethnicity,
 and
 therefore,
 one’s
 caste.
 
 
 However,
 the
 caste
 system
 is
 more
 complex
 
than
 simple
 facial
 features.
 
 For
 example,
 the
 Gurungs
 descended
 from
 Mongolia
 in
 
the
 6
th

 century,
 but
 have
 kept
 their
 distinct
 features
 intact
 over
 the
 centuries
 since
 
migration
 to
 Nepal.
 
 Their
 faces
 still
 resemble
 their
 Mongolian
 ancestors
 and
 are
 
easily
 spotted
 by
 the
 unaccustomed
 eye.
 
 Yet
 because
 the
 Gurungs
 practice
 Tibetan
 
Buddhism,
 not
 Hinduism
 like
 most
 other
 Nepalis,
 they
 are
 not
 bound
 by
 the
 caste
 
system.
 
 They
 make
 up
 over
 2
 percent
 of
 the
 population,
 and
 are
 simply
 referred
 to
 
as
 the
 Gurungs.
 
 
 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
5

 Rai,
 Bandana.
 
 Gorkhas:
 The
 Warrior
 Race.
 
 Guyan
 Publishing
 House.
 
 2009.
 
 Pages
 9-­‐
10.
 

 

 
6
 

 
To
 simplify
 the
 ethnic
 groups
 and
 castes,
 the
 Nepali
 government
 has
 provided
 
a
 general
 outline
 of
 the
 ethnic
 groups
 (and
 consequently
 the
 castes)
 in
 Nepal.
 
 Some
 
of
 the
 primary
 groups,
 as
 of
 the
 2001
 Nepali
 Census,
6

 are
 as
 follows:
 
Khas-­‐
 There
 are
 two
 primary
 castes
 of
 the
 Khas
 people,
 the
 Chhetri
 (15.5
 
percent
 of
 population)
 and
 the
 Bahun
 (12.5
 percent
 of
 the
 population).
 
 The
 Khasos
 
immigrated
 across
 the
 Himalayas,
 displacing
 the
 existing
 people.
 
 Together
 these
 two
 
castes
 make
 up
 28
 percent
 of
 the
 population
 of
 Nepal.
 
Magar-­‐
 The
 Magars
 are
 the
 largest
 indigenous
 people
 of
 Nepal.
 
 They
 
represent
 7.41
 percent
 of
 the
 population.
 
 Almost
 75
 percent
 of
 the
 Magars
 are
 
Hindu,
 while
 the
 remaining
 25
 percent
 are
 Buddhist.
 
Tharu-­‐
 The
 Tharu
 are
 the
 indigenous
 people
 of
 the
 Terai,
 the
 Southern
 
Foothills
 of
 the
 Himalayas.
 
 They
 inhabit
 the
 marshy
 grasslands
 and
 forests
 and
 are
 
known
 in
 part
 for
 their
 unusual
 resistance
 to
 Malaria.
 
 In
 1854,
 the
 Tharus
 were
 
placed
 in
 the
 lowest
 touchable
 caste,
 next
 to
 the
 Untouchables,
 by
 the
 Jung
 Bahadur,
 
the
 first
 Rana
 prime
 minister
 of
 Nepal.
 
 His
 Mulki
 Ain,
 a
 codification
 of
 Nepal’s
 
indigenous
 legal
 system,
 divided
 society
 into
 a
 system
 of
 castes.
 
 Today,
 the
 Tharus
 
make
 up
 6.6
 percent
 of
 the
 population.
 
Tamang-­‐
 The
 Tamangs
 are
 indigenous
 inhabitants
 of
 the
 Himalaya
 regions
 of
 
Tibet,
 Nepal
 and
 India.
 
 They
 have
 their
 own
 distinct
 culture,
 language
 and
 religion.
 
 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
6

 “Government
 of
 Nepal
 National
 Planning
 Commission
 Secretariat.”
 
 Central
 Bureau
 
of
 Statistics.
 http://www.cbs.gov.np/population_caste.php.
 18
 April,
 2012
 

 

 

 
7
 

 
They
 are
 the
 fifth
 largest
 ethnic
 group
 in
 Nepal,
 comprising
 5.5
 percent
 of
 the
 total
 
population.
 
Newar-­‐
 The
 Newars
 are
 the
 indigenous
 people
 and
 the
 creators
 of
 the
 culture
 
of
 the
 Kathmandu
 Valley.
 
 The
 Newars
 are
 the
 sixth
 largest
 ethnic
 group,
 
representing
 5.48
 percent
 of
 the
 population
 of
 Nepal.
7

 
 Their
 influence
 on
 the
 culture
 
and
 architecture
 are
 present
 throughout
 the
 Kathmandu
 Valley.
 
There
 is
 a
 multitude
 of
 cultures
 and
 dialects
 that
 converge
 in
 Nepal,
 
specifically
 in
 the
 Kathmandu
 Valley,
 and
 this
 diverse
 composition
 forms
 the
 
backdrop
 of
 a
 very
 unstable
 government.
 
 The
 political
 unrest
 in
 Nepal
 was
 
catapulted
 into
 the
 national
 spotlight
 in
 2001,
 when
 most
 of
 the
 Royal
 Family
 was
 
murdered
 by
 the
 Crown
 Prince
 Dipendra,
 including
 the
 Crown
 King
 Birendra,
 Crown
 
Queen
 Aishwarya
 and
 several
 other
 members
 of
 the
 family.
 
 
 Although
 there
 is
 no
 
concluding
 evidence,
 the
 massacre
 is
 widely
 believed
 to
 be
 a
 result
 of
 Prince
 
Dipendra’s
 impending
 marriage
 to
 Devyani
 Rana,
 a
 member
 of
 the
 rival
 Rana
 family
8
.
 
 
King
 Birendra’s
 brother,
 King
 Gyanendra,
 succeeded
 the
 throne,
 and
 the
 next
 several
 
years
 were
 fraught
 with
 disillusionment
 and
 instability
9
.
 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
7

 Government
 of
 Nepal
 National
 Planning
 Commission
 Secretariat.
 
 Central
 Bureau
 of
 
Statistics.
 http://www.cbs.gov.np/population_caste.php.
 18
 April,
 2012
 
8

 “Aishwarya:
 Nepal's
 forceful
 queen.”
 BBC
 News:
 World
 Edition.
 
http://news.bbc.co.uk/2/hi/south_asia/1369064.stm.
 5
 June
 2001.
 
9

 Khalid,
 Saif.
 “Nepal's
 Unfinished
 Revolution.”
 Al
 Jazeera.
 16
 May
 2012.
 
http://www.aljazeera.com/indepth/features/2012/05/2012516111455282372.ht
ml
 

 

 
8
 

 
The
 Unified
 Communist
 Party
 of
 Nepal,
 a
 Maoist
 regime,
 seized
 control
 of
 the
 
country
 during
 the
 Nepalese
 Constituent
 Assembly
 election
 in
 2008.
10

 
 The
 Unified
 
Communist
 Party
 of
 Nepal
 (Maoist)
 launched
 the
 “Nepalese
 People’s
 War”
 in
 1996,
 
and
 slowly
 gained
 support
 from
 the
 Nepali
 people,
 and
 in
 2001,
 the
 UCPN(M)
 
attacked
 the
 army
 for
 the
 first
 time.
 
 Following
 the
 demise
 of
 the
 Nepali
 crown,
 the
 
party
 received
 the
 largest
 votes
 in
 the
 2008
 election.
 
 The
 Communist
 influence
 is
 
evident
 throughout
 Nepal,
 from
 the
 hammer
 and
 sickle
 signs
 posted
 prevalently
 to
 
the
 red
 flags
 adorning
 the
 local
 busses.
 
 In
 such
 poverty
 and
 despair,
 many
 Nepalis
 
cling
 to
 the
 promises
 that
 the
 Maoists
 bring
 with
 them.
 

 

 

 

 

 

 

 

 

 

 

 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
10

 Kaphle,
 Anup.
 “Long
 stalemate
 after
 Maoist
 victory
 disrupts
 life
 in
 Nepal.”
 The
 
Washington
 Post.
 
 7
 July
 2010.
 http://www.washingtonpost.com/wp-­‐
dyn/content/story/2010/07/06/ST2010070605737.html?sid=ST2010070605737
 

 

 

 
9
 

 
Chapter
 Three:
 Changing
 Landscape
 and
 Development
 
This
 ever-­‐changing
 political
 landscape
 is
 the
 backdrop
 for
 the
 turbulent
 
cultural
 and
 economic
 state
 of
 Nepal.
 
 However,
 in
 1951,
 the
 ruling
 Ranas
 were
 
dedicated
 to
 improving
 the
 state
 of
 Nepal.
 
 Through
 the
 efforts
 of
 the
 successive
 
rulers
 over
 the
 last
 40
 years,
 both
 the
 life
 expectancy
 and
 literacy
 rates
 were
 
improved
11
.
 
 Additionally,
 villages
 began
 installing
 running
 water
 and
 latrines,
 which
 
helped
 contribute
 to
 the
 overall
 health
 and
 well
 being
 of
 residents.
 
 In
 the
 
Kathmandu
 Valley,
 as
 well
 as
 in
 other
 more
 rural
 areas,
 the
 swift
 and
 steady
 rise
 in
 
population
 (likely
 a
 result
 of
 these
 improvements)
 all
 but
 made
 these
 improvements
 
negligible.
 
 A
 1991
 census
 showed
 that
 since
 1954,
 the
 population
 had
 risen
 from
 8.4
 
million
 to
 18.5
 million.
 
 
 Today,
 approximately
 80
 percent
 of
 the
 people
 live
 in
 rural
 
areas
 and
 subside
 off
 of
 their
 own
 farming
 and
 agricultural
 practices.
 
 And,
 
considering
 that
 Nepal
 is
 a
 relatively
 poor
 country
 by
 world
 standards
 (157
th

 out
 of
 
187
 countries)
12
,
 the
 rise
 in
 population,
 combined
 with
 the
 fact
 that
 there
 have
 been
 
no
 agricultural
 advancements,
 has
 led
 to
 extremely
 poor
 living
 conditions.
 
 
 
By
 1980,
 Nepal’s
 net
 importation
 of
 grains
 highly
 outnumbered
 its
 net
 
exportation,
 leading
 to
 an
 overwhelming
 indebtedness
 and
 consequent
 emigration
 
from
 the
 city
 centers
 to
 the
 rural
 valleys
 and
 mountain
 regions.
 
 The
 outlying
 forests
 
shrunk
 and
 cultivatable
 land
 was
 diminished,
 creating
 deforestation
 and
 soil
 erosion.
 
 
As
 the
 population
 spread,
 the
 land
 was
 further
 injured,
 making
 it
 increasingly
 
difficult
 to
 maintain
 a
 steady
 agricultural
 workforce.
 
 
 Most
 people
 relocated
 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
11

 Whelpton,
 John.
 A
 History
 of
 Nepal.
 Cambridge
 University
 Press.
 Page
 122.
 
12

 http://www.ruralpovertyportal.org/web/guest/country/home/tags/nepal
 

 

 
10
 

 
permanently
 to
 the
 Terai
 (marshy
 grasslands,
 forests
 and
 savannahs
 in
 the
 foothills
 
of
 southern
 Nepal
13
),
 leaving
 the
 hills
 and
 mountains
 with
 few
 residents.
 
 Only
 12
 
percent
 of
 the
 Nepali
 population
 resided
 in
 urban
 areas
 in
 1991,
 although
 the
 
trending
 population
 increase
 still
 affected
 the
 Kathmandu
 Valley,
 with
 a
 300
 percent
 
increase
 in
 40
 years
14
.
 
Recognizing
 the
 growing
 need
 for
 improvements,
 the
 government
 established
 
a
 series
 of
 “five-­‐year
 plans”
 through
 the
 National
 Planning
 Commission
 initiated
 in
 
1955.
 
 Following
 the
 demise
 of
 the
 Rana
 family’s
 reign
 in
 1951,
 the
 new
 democratic
 
government
 was
 committed
 to
 the
 plans.
 
 The
 first
 plan
 was
 to
 improve
 the
 
infrastructure,
 by
 building
 new
 roads
 and
 increasing
 agricultural
 production.
 
 The
 
improvements
 gained
 speed
 when
 King
 Birendra
 came
 to
 the
 throne
 in
 the
 early
 
1970s.
 
 He
 divided
 the
 country
 into
 five
 development
 regions:
 Eastern,
 Central
 
(including
 the
 Kathmandu
 Valley),
 Western
 (including
 Pokhara),
 Mid-­‐Western
 and
 
Far
 Western.
 
 He
 focused
 on
 agriculture
 and
 resource
 conservation.
 
 However,
 the
 
efforts
 were
 futile,
 showing
 very
 few
 improvements
 beyond
 the
 merchant
 class,
 and
 
hardly
 raising
 the
 living
 standards
15
.
 
Another
 aspect
 of
 King
 Birendra’s
 progressive
 movement
 was
 the
 New
 
Education
 System,
 implemented
 in
 1972.
 
 The
 goal
 was
 to
 integrate
 a
 national
 
structure
 for
 schools
 and
 colleges
 to
 regulate
 them.
 
 Out
 of
 this,
 the
 literacy
 rate
 rose
 
from
 5
 percent
 in
 1954
 to
 48
 percent
 by
 2001.
 However,
 the
 system
 was
 designed
 to
 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
13

 Travel
 Guide:
 The
 Terai.
 Nepal
 Home
 Page.
 
http://www.nepalhomepage.com/travel/places/terai/terai.html
 
14

 Whelpton,
 John.
 A
 History
 of
 Nepal.
 Cambridge
 University
 Press.
 Pages
 122-­‐123.
 
15

 Whelpton,
 John.
 A
 History
 of
 Nepal.
 Cambridge
 University
 Press.
 Pages
 122-­‐128.
 

 

 
11
 

 
prepare
 students
 for
 vocational
 lines
 of
 work,
 and
 unfortunately,
 students
 were
 
dissatisfied
 with
 it,
 claiming
 it
 limited
 their
 education.
 
 While
 the
 efforts
 were
 well-­‐
intended,
 the
 economy
 could
 not
 sustain
 the
 many
 proposed
 advancements.
 
 Due
 to
 
the
 increasing
 number
 of
 imports
 and
 lack
 of
 sufficient
 revenue-­‐producing
 jobs
 in
 
Nepal,
 the
 country
 had
 to
 negotiate
 a
 loan
 from
 the
 World
 Bank
 in
 the
 mid-­‐1980s
16
.
 

 

 

 

 

 

 

 

 

 

 

 

 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
16

 Whelpton,
 John.
 A
 History
 of
 Nepal.
 Cambridge
 University
 Press.
 Page
 127.
 

 

 
12
 

 
Chapter
 Four:
 Women
 in
 Nepal
 
Around
 the
 world,
 organizations
 and
 agencies
 are
 working
 to
 increase
 the
 
considerably
 low
 number
 of
 female
 enrollment
 in
 schools
 in
 developing
 nations.
 
 
There
 is
 funding
 from
 many
 different
 programs,
 including
 USAID
 and
 World
 Bank,
 as
 
well
 as
 various
 governmental
 agencies.
 
 Research
 shows
 that
 young
 girls
 face
 
incredible
 obstacles
 to
 get
 to
 school,
 including,
 but
 not
 limited
 to,
 their
 parents’
 
socioeconomic
 status,
 religion
 and
 their
 distance
 to
 school
17
.
 
 Despite
 all
 of
 the
 other
 
factors
 that
 prevent
 a
 girl
 from
 attending
 school,
 the
 major
 obstacle
 in
 most
 cultures
 
is
 simply
 that
 she
 is
 female.
 
 In
 her
 book,
 “Gender
 Trouble
 Makers:
 Education
 and
 
Empowerment
 in
 Nepal,”
 Jennifer
 Rothchild
 argues
 that
 “we
 need
 to
 implement
 an
 
additional
 level
 of
 analysis
 by
 examining
 how
 gender,
 as
 a
 process,
 is
 constructed
 and
 
maintained
 in
 both
 homes
 and
 schools.
 
 By
 looking
 at
 gender
 as
 a
 process
 rather
 than
 
a
 demographic
 factor,
 we
 can
 begin
 to
 understand
 the
 obstacles
 and
 opportunities
 
for
 girls
 and
 boys
 in
 schools”
18
.
 
 She
 then
 notes
 that
 gender
 has
 been
 used
 to
 
legitimize
 inequalities
 in
 schools,
 and
 in
 doing
 so,
 gender
 impedes
 both
 boys’
 and
 
girls’
 ability
 to
 succeed
 in
 school
 and
 to
 raise
 their
 living
 standards
 at
 home.
 
 
Therefore,
 opportunities
 gained
 through
 education
 are
 lost.
 
 
 
Working
 toward
 equality
 in
 schools
 is
 more
 than
 just
 improving
 enrollment
 
figures.
 
 To
 achieve
 full
 equality,
 the
 climate
 inside
 the
 classroom
 should
 be
 
examined
 as
 well.
 
 It
 is
 not
 enough
 to
 have
 equitable
 enrollment
 in
 schools;
 what
 is
 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
17

 Rothchild,
 Jennifer.
 
 Gender
 Trouble
 Makers:
 Education
 and
 Empowerment
 in
 Nepal.
 
Routledge.
 New
 York,
 NY.
 2006.
 Page
 1.
 
18

 Rothchild,
 Jennifer.
 
 Gender
 Trouble
 Makers:
 Education
 and
 Empowerment
 in
 Nepal.
 
Routledge.
 New
 York,
 NY.
 2006.
 Page
 2.
 

 

 
13
 

 
needed
 is
 equal
 participation
 and
 interaction
 between
 the
 students
 and
 teachers.
 
 As
 
Rothchild
 notes,
 the
 education
 that
 students
 receive
 in
 the
 classroom
 extends
 beyond
 
those
 walls—they
 learn
 how
 to
 succeed
 in
 life,
 to
 raise
 their
 living
 standards,
 and
 to
 
better
 their
 own
 lives
 and
 the
 lives
 of
 their
 families.
 
 Additionally,
 education
 at
 home
 
is
 equally
 as
 important.
 
 In
 schools
 and
 at
 home,
 it
 is
 important
 to
 acknowledge
 that
 
gender
 is
 not
 simply
 a
 tool
 to
 differentiate
 one’s
 sex.
 
 Rather,
 it
 is
 a
 social
 construct,
 
constantly
 perpetuating
 inequalities.
 
 Gender
 is
 not
 just
 what
 we
 are,
 but
 what
 we
 
are
 allowed
 to
 do.
 
 By
 not
 recognizing
 this,
 the
 research
 is
 limited
 and
 prevents
 
proper
 focus
 on
 the
 problem
19
.
 
 
In
 short,
 while
 a
 woman’s
 experience
 in
 rural
 Nepal
 varies
 greatly
 from
 a
 
woman’s
 experience
 in
 urban
 America,
 
 what
 we
 learn
 from
 studying
 gender
 
inequalities
 here
 can
 perhaps
 be
 applied
 to
 a
 more
 universal
 understanding
 of
 
gender
 inequalities.
 

  While
 research
 into
 the
 educational
 system
 and
 enrollment
 is
 important
 and
 
relevant,
 perhaps
 a
 more
 telling
 study
 would
 be
 to
 examine
 the
 inequalities
 outside
 
of
 the
 school
 environment,
 specifically
 at
 home.
 
 Based
 on
 her
 research
 from
 both
 
Ashby
 (1985)
 and
 Jamison
 and
 Lockheed
 (1987),
 Rothchild
 argues
 that
 three
 main
 
factors
 prevent
 a
 young
 girl
 from
 pursuing
 an
 education:
 (1)
 daughters
 are
 expected
 
to
 marry
 at
 a
 young
 age
 and
 leave
 their
 households,
 while
 sons
 are
 expected
 to
 care
 
for
 their
 parents
 into
 old
 age;
 (2)
 men
 generally
 pursue
 non-­‐agricultural
 employment
 
more
 frequently
 than
 women
 because
 it
 is
 perceived
 as
 more
 appropriate;
 and
 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
19

 Rothchild,
 Jennifer.
 
 Gender
 Trouble
 Makers:
 Education
 and
 Empowerment
 in
 Nepal.
 
Routledge.
 New
 York,
 NY.
 2006.
 Page
 2-­‐4.
 

 

 
14
 

 
finally,
 (3)
 the
 gender-­‐based
 division
 of
 agricultural
 work
 for
 females
 requires
 more
 
of
 a
 routine
 than
 the
 work
 for
 males.
 
 
 For
 example,
 the
 women
 are
 expected
 to
 
perform
 the
 cooking,
 cleaning
 and
 gathering
 duties,
 which
 demand
 consistent
 
attention.
 
 The
 women
 are
 responsible
 for
 caring
 for
 the
 children
 and
 animals
 and
 
providing
 food
 for
 their
 families.
 
 Therefore,
 without
 the
 women’s
 consistent
 
devotion
 to
 their
 tasks
 ,
 their
 families
 would
 greatly
 suffer.
 
 Jamison
 and
 Lockheed
 
further
 argue
 that
 girls
 are
 discouraged
 by
 their
 families
 and
 by
 society
 from
 
attending
 school
 because
 they
 are
 needed
 to
 care
 for
 their
 younger
 siblings.
 
 Given
 
these
 pressures,
 the
 very
 fact
 that
 girls
 even
 enroll
 in
 school
 might
 be
 considered
 a
 
victory
 in
 itself.
 
 While
 men
 leave
 the
 house
 to
 pursue
 an
 education
 and
 provide
 for
 
the
 family,
 women
 traditionally
 stay
 at
 home
 and
 care
 for
 the
 household
 and
 the
 
family.
 
 This
 is
 due
 to
 the
 widely-­‐held
 belief
 that
 women
 are
 more
 suited
 for
 this
 
home-­‐based
 kind
 of
 work,
 that
 they
 are
 more
 nurturing
 and
 better
 endowed
 to
 raise
 
children.
 
 “Parents
 often
 perceive
 daughter
 as
 responsible
 for
 household
 chores
 and
 
childcare.
 
 This
 division
 of
 labor,
 most
 often
 guided
 by
 patriarchal
 ideology,
 is
 based
 
on
 the
 notion
 that
 women
 are
 “naturally”
 and
 distinctively
 endowed
 to
 nurture
 and
 
raise
 children
 as
 well
 as
 take
 care
 of
 their
 husbands
 and
 families.”
20

 
 As
 Rothchild
 
indicates,
 daughters’
 greatest
 economic
 value
 for
 their
 households
 is
 during
 their
 
teen
 years
 when
 they
 contribute
 labor,
 which
 happens
 to
 coincide
 with
 schooling
 
years.
 
 
 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
20

 Rothchild,
 Jennifer.
 
 Gender
 Trouble
 Makers:
 Education
 and
 Empowerment
 in
 Nepal.
 
Routledge.
 New
 York,
 NY.
 2006.
 Page
 7
 

 

 
15
 

 
The
 economic
 advantage
 of
 having
 a
 boy
 over
 a
 girl
 is
 not
 lost
 on
 those
 in
 the
 
rural
 villages.
 
 In
 Rupakot,
 a
 small
 village
 in
 the
 Lamjung
 Valley
 near
 Kathmandu,
 
Nepal
 where
 the
 author
 recently
 visited,
 mothers
 inquire
 about
 the
 gender
 of
 their
 
unborn
 babies.
 
 Abortions
 are
 common,
 and
 not
 frowned
 upon.
 
 In
 fact,
 if
 a
 pregnant
 
woman
 learns
 she
 is
 carrying
 a
 daughter,
 she
 is
 often
 encouraged
 to
 terminate
 the
 
pregnancy.
 
 The
 author
 was
 told
 a
 story
 of
 a
 young
 mother
 in
 Rupakot
 who
 delivered
 
two
 healthy
 baby
 boys,
 both
 of
 whom
 died
 before
 the
 age
 of
 1.
 
 Following
 her
 first
 
two
 births,
 she
 delivered
 5
 girls
 consecutively.
 
 While
 pregnant
 with
 her
 sixth
 child,
 
she
 learned
 it
 would
 be
 another
 girl,
 and
 at
 the
 insistence
 of
 her
 neighbors
 and
 with
 
her
 own
 inclination,
 she
 aborted
 the
 child.
 
The
 gender
 relations
 and
 familial
 dynamics
 are
 complex,
 but
 very
 important
 to
 
understand
 for
 anyone
 wanting
 to
 help
 improve
 the
 health
 of
 Nepal.
 
 One
 of
 the
 most
 
striking
 health
 problems
 is
 the
 rate
 of
 maternal
 deaths,
 which
 stems
 from
 the
 care
 
that
 expectant
 mothers
 and
 their
 infants
 receive.
 

 

 

 

 

 

 

 

 

 

 
16
 

 
Chapter
 Five:
 Maternal
 Health
 and
 Mortality
 in
 Nepal
 
The
 World
 Health
 Organization
 (WHO)
 defines
 “maternal
 death”
 as
 “the
 death
 
of
 a
 woman
 while
 pregnant
 or
 within
 42
 days
 of
 termination
 of
 pregnancy,
 
irrespective
 of
 the
 duration
 and
 site
 of
 the
 pregnancy,
 from
 any
 cause
 related
 to
 or
 
aggravated
 by
 the
 pregnancy
 or
 its
 management
 but
 not
 from
 accidental
 or
 incidental
 
causes"
21
.
 
 It
 is
 estimated
 that
 in
 2005,
 half
 a
 million
 women,
 most
 of
 them
 in
 
developing
 countries,
 died
 each
 year
 of
 complications
 during
 pregnancy
 or
 
childbirth.
 
 One-­‐third
 of
 these
 women
 were
 located
 in
 the
 WHO
 South-­‐East
 Asia
 
Region
22
.
 
 According
 to
 a
 year-­‐long
 study
 from
 April
 2008
 to
 April
 2009
 carried
 out
 in
 
eight
 districts
 in
 Nepal,
 maternal
 deaths
 accounted
 for
 11
 percent
 of
 all
 women
 of
 
reproductive
 age
 (WRA)
 deaths.
 
 The
 districts
 were
 Rupandehi,
 Kailali,
 Okhaldhunga,
 
Surkhet,
 Jumla,
 Baglung,
 Rasuwa
 and
 Sunsari.
 
 The
 total
 population
 of
 the
 study
 
districts
 was
 3.2
 million,
 comprising
 12
 percent
 of
 Nepal’s
 population.
 
 All
 of
 the
 
areas
 have
 high
 proportions
 of
 rural
 populations
 (approximately
 74-­‐100
 percent).
 
 
The
 study,
 entitled
 “NEPAL:
 Maternal
 Mortality
 and
 Morbidity
 Study
 (MMMS),”
 was
 
conducted
 under
 the
 management
 of
 the
 Family
 Health
 Division
 (FHD)
 of
 the
 
Department
 of
 Health
 Services
 (DoHS),
 with
 assistance
 from
 various
 other
 
organizations
23
.
 
 The
 chart
 below
 highlights
 data
 regarding
 WRA
 mortality
 in
 the
 
aforementioned
 districts.
 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
21

 Health
 Statistics
 and
 Health
 Information
 Services.
 World
 Health
 Organization.
 
http://www.who.int/healthinfo/statistics/indmaternalmortality/en/index.html
 
22

 World
 Health
 Statistics.
 World
 Health
 Organization.
 
http://www.who.int/whosis/whostat/EN_WHS10_Full.pdf.
 2010.
 

 

 

 
17
 

 
Table
 1:
 Levels
 of
 all-­‐cause
 mortality
 among
 women
 of
 reproductive
 age
 2008-­‐
2009
24

 

 
District
  Number
 of
 
WRA
 

 (15-­‐49
 
yrs.)
 
Number
 of
 
WRA
 
deaths
 
Number
 of
 
non-­‐
pregnancy
 
related
 
deaths
 of
 
WRA
 
Total
 
death
 rate
 
per
 
100,000
 
WRA
 
Non-­‐
pregnancy
 
related
 
death
 rate
 
per
 
100,000
 
WRA
 
Sunsari
  199,080
  327
  300
  164
  151
 
Rupandehi
  216,795
  340
  290
  157
  134
 
Kailali
  190,635
  417
  370
  219
  194
 
Okhaldhunga
  44,360
  61
  56
  138
  126
 
Baglung
  82,993
  100
  89
  120
  107
 
Surkhet
  89,161
  153
  134
  172
  150
 
Rasuwa
  12,
 451
  18
  15
  145
  120
 
Jumla
  25,837
  80
  70
  310
  271
 
Total
  861,312
  1,496
  1,324
  174
  154
 

 
The
 average
 death
 rate
 was
 174
 per
 100,000
 WRA,
 with
 the
 lowest
 recorded
 in
 
Baglung
 at
 120
 per
 100,000
 WRA
 and
 in
 Okhaldhunga
 at
 138
 per
 100,000
 WRA.
 
 The
 
highest
 rates
 were
 in
 Kailali
 and
 Jumla,
 with
 219
 per
 100,000
 WRA
 and
 310
 per
 
100,000
 WRA,
 respectively.
 
 The
 average
 non-­‐pregnancy
 related
 deaths
 for
 the
 eight
 
listed
 regions
 was
 154
 per
 100,000
 WRA.
 
 It
 is
 important
 to
 note
 that
 over
 the
 course
 
of
 the
 study,
 the
 researchers
 found
 that
 maternal
 causes
 accounted
 for
 93
 percent
 of
 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
23

 Suvedi,
 Bal
 Krishna,
 et
 al.
 2009.
 “Nepal
 Maternal
 Mortality
 and
 Morbidity
 Study
 
2008/2009:
 Summary
 of
 Preliminary
 Findings.”
 Kathmandu,
 Nepal.
 Family
 Health
 
division,
 Department
 of
 Health
 Services,
 Ministry
 of
 Health,
 Government
 of
 Nepal.
 2009.
 
Kathmandu,
 Nepal.
 
24

 Suvedi,
 et
 al.
 “Nepal
 Maternal
 Mortality
 and
 Morbidity
 Study
 2008/2009:
 Summary
 
of
 Preliminary
 Findings.”
 Family
 Health
 Division,
 Department
 of
 Health
 Services,
 
Ministry
 of
 Health,
 Government
 of
 Nepal.
 Table
 1:
 Levels
 of
 all-­‐cause
 mortality
 among
 
women
 of
 reproductive
 age.
 Page
 5.
 Kathmandu,
 Nepal.
 2009.
 
 

 

 

 
18
 

 
pregnancy-­‐related
 deaths,
 and
 they
 accounted
 for
 11
 percent
 of
 all
 deaths
 of
 WRA.
 
 
This
 number,
 however,
 is
 down
 from
 21
 percent
 in
 1998.
25

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
25

 Suvedi,
 Bal
 Krishna,
 et
 al.
 2009.
 “Nepal
 Maternal
 Mortality
 and
 Morbidity
 Study
 
2008/2009:
 Summary
 of
 Preliminary
 Findings.”
 Family
 Health
 division,
 Department
 
of
 Health
 Services,
 Ministry
 of
 Health,
 Government
 of
 Nepal.
 2009.
 Kathmandu,
 Nepal.
 

 

 
19
 

 
Chapter
 Six:
 Causes
 of
 Maternal
 Death
 
The
 two
 most
 common
 causes
 of
 maternal
 deaths
 are
 hemorrhage
 and
 
eclampsia,
 both
 of
 which
 are
 generally
 monitored
 and
 averted
 in
 developed
 
countries
26
;
 however,
 in
 Nepal,
 the
 means
 to
 control
 them
 aren’t
 available.
 
 As
 the
 
chart
 below
 demonstrates,
 many
 of
 the
 most
 common
 causes
 of
 maternal
 deaths
 in
 
Nepal
 could
 be
 prevented
 with
 proper
 care.
 
 The
 second
 leading
 cause
 of
 death
 is
 
eclampsia,
 a
 condition
 that,
 if
 caught
 while
 still
 in
 the
 preeclampsia
 stage,
 can
 be
 
avoided.
 
 Similarly,
 anemia
 is
 another
 treatable
 condition
 if
 properly
 diagnosed.
 
 
According
 to
 Drs.
 Bertram
 Sohl
 and
 Hadi
 Emamian,
 obstetricians
 at
 St.
 Mary’s
 
Medical
 Center
 in
 Long
 Beach,
 California,
 anemia
 in
 pregnant
 women
 in
 developing
 
nations
 is
 most
 commonly
 caused
 by
 worms
27
.
 
 Therefore,
 providing
 treatment
 to
 
deworm
 women
 would
 help
 avoid
 anemia.
 
 In
 their
 opinion,
 the
 most
 important
 
condition
 to
 monitor
 is
 anemia
 because
 it
 is
 the
 most
 easily
 treated.
 
 The
 following
 
chart
 shows
 a
 breakdown
 of
 the
 causes
 of
 maternal
 death
 in
 Nepal,
 according
 to
 the
 
MMM
 Study.
 
 
 

 

 

 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
26

 Pacheco,
 Louis
 D.,
 M.D.
 and
 Steven
 L.
 Clark,
 M.D.
 A
 Review
 of
 Research
 on
 Maternal
 
Hemorrhage.
 Contemporary
 OB/GYN.
 1
 June
 2012.
 
http://www.modernmedicine.com/modernmedicine/article/articleDetail.jsp?id=77
7249
 
27

 Dr.
 Sohl,
 Bertram,
 M.D.
 and
 Dr.
 Hadi
 Emamian,
 M.D..
 Personal
 Interview.
 California,
 
March
 2012.
 

 

 
20
 

 
Figure
 1:
 Causes
 of
 Maternal
 Deaths
 in
 rural
 Nepal,
 2008-­‐2009
28

 

 

 

 

 

 

 

 

 

 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
28

 Suvedi,
 et
 al.
 “Nepal
 Maternal
 Mortality
 and
 Morbidity
 Study
 2008/2009:
 Summary
 
of
 Preliminary
 Findings.”
 Family
 Health
 division,
 Department
 of
 Health
 Services,
 
Ministry
 of
 Health,
 Government
 of
 Nepal.
 2009.
 Kathmandu,
 Nepal.
 
 Figure
 3:
 Causes
 of
 
maternal
 deaths.
 Page
 10.
 

 
Hemorrhage
 
24%
 
Eclampsia
 
21%
 
Other
 indirect
 
16%
 
Other
 direct
 
6%
 
Abortion
 
7%
 
Heart
 disease
 
7%
 
Obstructed
 labor
 
6%
 
Anemia
 
4%
 
Gastroenteritis
 
4%
 
Puerperal
 sepsis
 
5%
 
Causes
 of
 maternal
 deaths
 

 

 
21
 

 
Chapter
 Seven:
 Timing
 of
 Pregnancy-­‐Related
 Deaths
 
There
 are
 three
 stages
 of
 birth:
 antepartum,
 or
 occurring
 before
 birth;
 
intrapartum,
 or
 occurring
 during
 birth;
 and
 postpartum,
 or
 occurring
 after
 birth.
 
 The
 
intrapartum
 period
 covers
 the
 delivery
 itself
 and
 up
 to
 48
 hours
 after
 birth.
 
 
Postpartum
 occurs
 any
 time
 from
 48
 hours
 after
 birth
 to
 42
 days
 after
 birth.
 
 
According
 to
 the
 Maternal
 Mortality
 and
 Morbidity
 Study
 conducted
 in
 the
 eight
 rural
 
districts
 in
 Nepal,
 all
 non-­‐maternal
 pregnancy-­‐related
 deaths
 that
 occurred
 during
 
the
 13
 month
 period,
 occurred
 during,
 rather
 than
 immediately
 after,
 pregnancy
29
.
 
 
In
 other
 words,
 when
 a
 mother
 dies
 from
 reasons
 unrelated
 to
 her
 pregnancy,
 it
 most
 
commonly
 happens
 prior
 to
 the
 delivery.
 
 The
 causes
 are
 generally
 suicide,
 homicide,
 
or
 accident.
 
 These
 three
 causes
 point
 to
 the
 presence
 of
 an
 unwanted
 pregnancy,
 so
 
the
 death
 of
 the
 mother,
 through
 suicide,
 homicide
 or
 accident,
 may
 often
 be
 an
 
attempt
 to
 prevent
 the
 birth
 of
 an
 unwanted
 child.
 
 
 
The
 data
 for
 pregnancy-­‐related
 maternal
 deaths
 in
 the
 eight
 districts
 are
 also
 
significant.
 
 While
 the
 importance
 of
 the
 presence
 of
 a
 skilled
 birth
 attendant
 is
 
undeniable,
 the
 MMM
 study
 points
 to
 the
 importance
 of
 antepartum
 and
 postpartum,
 
as
 opposed
 to
 just
 intrapartum,
 care.
 
 Approximately
 61
 percent
 of
 the
 maternal
 
deaths
 occur
 in
 the
 antepartum
 and
 postpartum
 periods
30
.
 
 This
 is
 when
 the
 mother
 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
29

 Suvedi,
 et
 al.
 “Nepal
 Maternal
 Mortality
 and
 Morbidity
 Study
 2008/2009:
 Summary
 
of
 Preliminary
 Findings.
 “Family
 Health
 division,
 Department
 of
 Health
 Services,
 
Ministry
 of
 Health,
 Government
 of
 Nepal.
 2009.
 Kathmandu,
 Nepal.
 Timing
 of
 
Pregnancy
 Related
 Deaths.
 Page
 10.
 

 

 

 

 
22
 

 
is
 most
 at-­‐risk
 for
 the
 two
 leading
 causes
 of
 maternal
 deaths—hemorrhage
 and
 
eclampsia.
 
 For
 this
 reason,
 more
 hospitals
 in
 Nepal
 are
 offering
 antepartum
 care
 for
 
pregnant
 women.
 
 They
 stress
 the
 importance
 of
 scheduled
 check-­‐ups
 and
 clinics
 
throughout
 the
 pregnancy,
 however
 many
 women
 do
 not
 attend
 these.
 
 There
 are
 
three
 reasons
 given
 for
 the
 women’s
 absence:
 1)
 they
 have
 no
 way
 to
 get
 there,
 2)
 
they
 are
 not
 aware
 of
 the
 positive
 impact
 that
 the
 clinics
 have,
 or
 3)
 they
 simply
 do
 
not
 know
 about
 these
 options.
 
 This
 presents
 a
 key
 public
 relations
 opportunity
 to
 
better
 communicate
 the
 importance
 of
 these
 clinics
 and
 to
 organize
 ways
 to
 make
 it
 
easier
 for
 the
 women
 to
 attend.
 
 
 

 

 

 

 

 

 

 

 

 

 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
30

 Suvedi,
 et
 al.
 “Nepal
 Maternal
 Mortality
 and
 Morbidity
 Study
 2008/2009:
 Summary
 
of
 Preliminary
 Findings.”
 Family
 Health
 division,
 Department
 of
 Health
 Services,
 
Ministry
 of
 Health,
 Government
 of
 Nepal.
 2009.
 Kathmandu,
 Nepal.
 
 Timing
 of
 
Pregnancy
 Related
 Deaths,
 Page
 10.
 

 

 
23
 

 
Chapter
 Eight:
 Place
 of
 Pregnancy-­‐Related
 Deaths
 
According
 to
 Nepal’s
 Maternal
 Mortality
 and
 Morbidity
 Study,
 41
 percent
 of
 
pregnancy-­‐related
 deaths
 occurred
 at
 a
 health
 care
 facility.
 
 Perhaps
 even
 more
 
striking
 is
 that
 this
 number
 is
 up
 from
 21
 percent
 in
 1998.
 
 This
 is
 a
 major
 cause
 for
 
concern
 considering
 that,
 in
 developed
 countries,
 a
 person
 is
 usually
 expected
 to
 
make
 a
 full
 recovery
 once
 he
 or
 she
 is
 in
 the
 hands
 of
 doctors.
 
 There
 are
 several
 
reasons
 why
 this
 is
 not
 necessarily
 the
 case
 in
 rural
 Nepal.
 
 First,
 pregnant
 women
 
and
 their
 families
 may
 be
 unaware
 or
 unable
 to
 recognize
 signs
 of
 complications
 and
 
distress.
 
 Geography
 may
 be
 another
 constraint;
 once
 they
 recognize
 a
 complication,
 
the
 nearest
 health
 care
 facility
 is
 often
 several
 miles
 away,
 to
 which
 they
 usually
 have
 
to
 walk.
 Finally,
 when
 the
 mother
 arrives
 at
 the
 hospital,
 the
 medical
 facilities
 are
 
often
 understaffed,
 lacking
 proper
 or
 enough
 equipment,
 and
 absent
 of
 sufficiently
 
skilled
 attendants
 and
 doctors.
 
 In
 an
 interview
 the
 author
 conducted
 with
 Katie
 
Lillie,
 an
 American
 teacher
 who
 works
 in
 the
 Lamjung
 Valley,
 Lillie
 noted
 that
 “It
 
seems
 to
 me
 that
 when
 Nepali
 people
 go
 to
 the
 hospital
 for
 almost
 any
 reason,
 all
 too
 
often
 the
 doctors
 always
 run
 urine
 and
 blood
 tests,
 take
 an
 x-­‐ray
 and
 hardly
 ever
 
seem
 to
 find
 the
 problem…I’m
 not
 sure
 if
 it’s
 the
 lack
 of
 training
 or
 lack
 of
 equipment
 
or
 a
 combination,
 but
 I
 feel
 like
 something
 has
 to
 change”
31
.
 
 The
 following
 chart
 
outlines
 the
 breakdown
 of
 the
 locations
 of
 pregnancy-­‐related
 deaths
 in
 the
 eight
 
districts
 studied
 in
 the
 MMM
 Study.
 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
31

 Lillie,
 Katie.
 Personal
 Interview.
 
 February,
 2012.
 

 

 
24
 

 
Figure
 2:
 Place
 of
 Pregnancy
 Related
 Deaths
 in
 rural
 Nepal,
 2008-­‐2009
32

 

 

 

 

 

 

 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
32

 Suvedi,
 et
 al.
 2009.
 “Nepal
 Maternal
 Mortality
 and
 Morbidity
 Study
 2008/2009:
 
Summary
 of
 Preliminary
 Findings.”
 Family
 Health
 division,
 Department
 of
 Health
 
Services,
 Ministry
 of
 Health,
 Government
 of
 Nepal.
 Case
 Study:
 Suicide
 of
 a
 Pregnant
 
Woman.
 2009.
 Kathmandu,
 Nepal.
 Page
 11.
 

 

 
Facility
 
42%
 
Home
 (own/
relative)
 
40%
 
Home
 (provider)
 
 
1%
 
Pharmacy
 
1%
 
Transit
 
from
 home
 
to
 Facility
 
7%
 
Transit
 
from
 
facility
 to
 
facility
 
5%
 
Transit
 
from
 
facility
 to
 
home
 
2%
 
Other
 
2%
 
Place
 of
 pregnancy
 related
 deaths
 

 

 
25
 

 
Chapter
 Nine:
 Hospital
 or
 Health
 Care
 Facility
 Deaths
 
It
 is
 common
 in
 developed
 countries
 for
 expectant
 mothers
 to
 research
 
hospitals
 or
 health
 care
 facilities
 at
 which
 they
 will
 deliver
 their
 babies.
 
 One
 of
 the
 
key
 factors
 in
 an
 expectant
 mother’s
 decision-­‐making
 process
 is
 the
 facility’s
 
Maternal
 Mortality
 Rate
 (MMR).
 
 An
 average
 overall
 hospital-­‐based
 MMR
 in
 the
 
Nepali
 Maternal
 Mortality
 and
 Morbidity
 Study
 was
 267
 per
 100,000.
 
 According
 to
 
the
 report,
 one
 of
 the
 primary
 causes
 of
 death
 at
 a
 facility
 in
 rural
 Nepal
 was
 delays,
 
either
 from
 the
 inability
 to
 treat
 the
 problem
 at
 the
 site
 of
 death,
 the
 inability
 to
 treat
 
the
 problem
 at
 the
 previous
 site,
 and
 inadequate
 clinical
 expertise.
 
 Additionally,
 lack
 
of
 transportation
 between
 the
 facilities
 and
 lack
 of
 blood
 contributed
 to
 the
 death
 
toll.
 
 In
 the
 2008/2009
 study,
 providers
 identified
 “lack
 of
 blood”
 as
 an
 avoidable
 
factor
 in
 12
 percent
 of
 the
 facilities.
 
 In
 Nepal’s
 Lamjung
 Valley,
 there
 are
 four
 
ambulances
 for
 400,000
 residents.
 
 Even
 if
 an
 ambulance
 is
 available,
 it
 may
 still
 take
 
up
 to
 two
 hours
 for
 the
 vehicle
 to
 reach
 the
 patient.
 
 There
 are
 many
 houses
 at
 the
 
tops
 of
 hills
 where
 an
 ambulance
 cannot
 drive,
 requiring
 either
 the
 patient
 to
 walk
 or
 
be
 carried
 down
 to
 the
 waiting
 ambulance.
 
 Furthermore,
 the
 ride
 to
 the
 hospital
 is
 
bumpy
 and
 uncomfortable—which
 can
 add
 further
 complications
 for
 the
 patient.
 
 
The
 ambulance
 ride
 costs
 NRS
 8,000,
 which
 is
 $100.
 
 It
 is
 unlikely
 that
 an
 average
 
family
 can
 afford
 this;
 therefore,
 the
 expectant
 mother’s
 only
 other
 options
 are
 to
 
take
 the
 local
 bus,
 which
 is
 an
 even
 more
 difficult
 journey
 to
 endure,
 or
 to
 deliver
 at
 
home.
 

 

 

 
26
 

 
Chapter
 Ten:
 Lamjung
 and
 Tanahun
 Valley
 Births
 
The
 Lamjung
 and
 Tanahun
 Valleys,
 the
 site
 of
 Avasar
 Nepal’s
 focus,
 is
 located
 
at
 the
 base
 of
 the
 Annapurna
 Mountain
 Range.
 
 Along
 with
 Mount
 Everest
 and
 K2,
 
Annapurna
 is
 a
 member
 of
 the
 “eight-­‐thousanders.”
 
 It
 is
 composed
 of
 a
 section
 of
 the
 
Himalayas
 in
 north-­‐central
 Nepal.
 
 Unfortunately,
 in
 the
 midst
 of
 this
 supreme
 
natural
 landscape,
 live
 people
 struggling
 to
 survive.
 
 Mr.
 Basaula,
 the
 founder
 of
 
Avasar,
 gathered
 statistics
 regarding
 the
 hospitals
 in
 the
 area.
 
 
 
Table
 2:
 Comparison
 of
 babies
 born
 to
 miscarriages
 in
 the
 Tanahun
 and
 
Lamjung
 Valley
 districts,
 2011
33

 

 
VDC
 Name
  District
  Population
  Babies
 born
 
each
 year
 
Miscarriages
 
Parewadanda
  Lamjung
  7500
  89
  150
 
Rupakot
  Tanahun
  8500
  99
  190
 
Kunchha
  Lamjung
  5500
  56
  115
 
Duradanda
  Lamjung
  7000
  71
  125
 
Bangre
  Lamjung
  5500
  65
  170
 
Jita
  Lamjung
  6500
  67
  140
 
Risti
  Tanahun
  6500
  75
  175
 

 
In
 the
 Lamjung
 and
 Tanahun
 Valleys,
 the
 number
 of
 miscarriages
 is
 almost
 
double
 the
 number
 of
 live
 births.
 
 However,
 when
 a
 baby
 is
 delivered
 in
 a
 hospital
 or
 
in
 the
 presence
 of
 a
 midwife
 or
 skilled
 birth
 attendant,
 the
 probability
 of
 a
 “good”
 
delivery
 increases
 by
 about
 80
 percent
34
.
 
 In
 these
 villages,
 about
 70
 percent
 of
 the
 
women
 can
 afford
 to
 travel
 to
 Pokhara,
 the
 second
 largest
 city
 in
 Nepal
 and
 closer
 
than
 Kathmandu,
 in
 order
 to
 better
 ensure
 a
 healthy
 delivery.
 
 However,
 if
 there
 are
 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
33

 “Comparison
 of
 babies
 born
 to
 miscarriages
 in
 the
 Tanahun
 and
 Lamjung
 Valleys
 
from
 2011.”
 
 Statistics
 provided
 by
 Nabaraj
 Basaula,
 January,
 2012.
 
34

 Poudel,
 Bimala,
 RHP
 Midwife.
 Personal
 Interview.
 Rupakot,
 Nepal,
 April
 16,
 2012.
 

 

 
27
 

 
further
 complications
 that
 require
 the
 doctors
 or
 instruments
 in
 Kathmandu,
 it
 is
 
unlikely
 that
 the
 woman
 will
 travel
 the
 8
 hours
 by
 bus
 to
 the
 capital.
 
 During
 the
 
author’s
 stay
 in
 the
 Lamjung
 Valley,
 a
 woman
 brought
 a
 small
 infant
 to
 the
 health
 
post.
 
 The
 baby
 was
 her
 granddaughter,
 and
 the
 baby’s
 mother,
 the
 woman’s
 
daughter-­‐in-­‐law,
 was
 too
 sick
 to
 bring
 the
 baby
 in
 herself.
 
 The
 family
 traveled
 to
 the
 
province
 of
 Chitwan,
 where
 the
 still-­‐pregnant
 mother
 was
 referred
 to
 Kathmandu.
 
 
Lacking
 the
 funds
 and
 means
 to
 get
 there,
 the
 mother
 delivered
 her
 child
 and
 
returned
 to
 her
 home
 in
 Rupakot.
 
 The
 baby
 weighed
 approximately
 2
 kilos
 and
 was
 
visibly
 underweight
 with
 a
 large
 mass
 on
 her
 spine.
 
 She
 had
 spina
 bifida.
 
 
 
The
 grandmother
 brought
 the
 baby
 in
 to
 have
 the
 dressings
 on
 the
 mass
 
changed.
 
 The
 baby
 was
 paralyzed
 from
 the
 waist
 down
 and
 had
 not
 gained
 weight
 in
 
her
 10
 days
 of
 life.
 
 However,
 the
 mother’s
 condition
 was
 even
 worse.
 
 She
 had
 severe
 
anemia
 from
 her
 C-­‐section
 wound
 that
 had
 not
 healed.
 
 Without
 the
 means
 to
 pay
 for
 
medicine
 or
 medical
 attention,
 the
 best
 she
 could
 do
 was
 eat
 leafy
 greens
 to
 increase
 
her
 iron
 count
 and
 drink
 water.
 
 As
 for
 the
 baby,
 the
 family
 had
 decided
 that
 her
 life
 
would
 be
 too
 difficult
 in
 that
 environment
 to
 make
 it
 worthwhile.
 
 A
 child
 with
 spina
 
bifida
 may
 have
 a
 difficult
 life
 in
 well-­‐developed
 countries,
 but
 in
 Nepal,
 the
 family
 
considered
 it
 was
 better
 off
 not
 living
 at
 all.
 
 
 
The
 dynamics
 of
 this
 family
 were
 complicated.
 
 The
 baby’s
 mother
 was
 her
 
father’s
 second
 wife,
 and
 both
 wives
 lived
 in
 the
 small
 clay
 house
 together,
 along
 
with
 their
 mother-­‐
 and
 father-­‐in-­‐law
 and
 the
 first
 wife’s
 three
 children.
 
 The
 husband
 

 

 
28
 

 
had
 left
 in
 May
 for
 work
 in
 Qatar.
 
 In
 Nepal,
 many
 men
 find
 work
 in
 the
 Middle
 East
 
to
 provide
 for
 their
 families.
 
 However,
 many
 of
 them
 do
 not
 return.
 
 
 
The
 clinicians
 at
 the
 health
 post
 asked
 questions
 in
 an
 attempt
 to
 understand
 
the
 reason
 for
 the
 baby’s
 size
 (for
 example,
 if
 the
 baby
 was
 delivered
 prematurely),
 
but
 the
 mother
 said
 that
 her
 pregnancy
 lasted
 from
 May-­‐April—10
 months.
 
 The
 
reason
 for
 her
 response
 may
 have
 been
 ignorance
 (perhaps
 she
 had
 miscarried
 at
 
some
 point
 early
 on
 in
 the
 pregnancy
 without
 knowing
 and
 then
 had
 become
 
pregnant
 again),
 or
 a
 deliberate
 inaccuracy.
 
 Since
 her
 husband
 had
 been
 gone
 since
 
May,
 and
 her
 child
 was
 born
 in
 April,
 it
 was
 technically
 impossible
 that
 her
 husband
 
is
 the
 father
 of
 her
 child.
 
 This
 means
 that
 she
 had
 either
 committed
 adultery
 or
 was
 
raped.
 
 Unfortunately,
 given
 that
 she
 lived
 with
 her
 father-­‐in-­‐law,
 the
 clinicians
 
tended
 to
 believe
 he
 had
 raped
 and
 impregnate
 her.
 
 She
 likely
 lied
 to
 protect
 herself,
 
her
 child
 and
 her
 family.
 
 As
 discussed
 in
 the
 Maternal
 Mortality
 and
 Morbidity
 Study,
 
rape
 by
 a
 family
 member
 is
 common,
 and
 often
 causes
 tension
 in
 the
 family.
 
 Because
 
of
 women’s
 status
 in
 the
 Nepali
 culture,
 as
 previously
 discussed,
 in
 these
 cases
 it
 is
 
also
 common
 for
 the
 woman
 to
 go
 to
 great
 lengths
 to
 avoid
 admitting
 to
 the
 truth,
 
whether
 it
 be
 through
 simple
 omission,
 or
 in
 more
 extreme
 cases,
 suicide
35
.
 While
 
the
 situation
 with
 the
 woman
 in
 Rupakot
 was
 very
 complicated,
 the
 one
 certainty
 is
 
that
 she
 was
 intentionally
 hiding
 something.
 
 Unfortunately,
 failure
 to
 care
 for
 the
 
unwanted
 baby
 had
 tragic
 consequences.
 
 One
 week
 after
 the
 author
 returned
 home
 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
35

 Suvedi,
 et
 al.
 “Nepal
 Maternal
 Mortality
 and
 Morbidity
 Study
 2008/2009:
 Summary
 
of
 Preliminary
 Findings.”
 Family
 Health
 division,
 Department
 of
 Health
 Services,
 
Ministry
 of
 Health,
 Government
 of
 Nepal.
 2009.
 Kathmandu,
 Nepal.
 Case
 Study:
 Suicide
 
of
 a
 Pregnant
 Woman.
 Page
 9.
 

 

 
29
 

 
Nepal,
 she
 learned
 that
 the
 baby
 had
 passed
 away.
 
 The
 clinicians
 noted
 that,
 had
 the
 
mother
 taken
 folic
 acid
 supplements,
 a
 basic
 prenatal
 supplement,
 during
 her
 
pregnancy,
 she
 likely
 would
 have
 delivered
 a
 healthy
 baby
 girl.
 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
30
 

 
Chapter
 Eleven:
 Mental
 Health
 
Along
 with
 the
 medical
 illnesses
 followed
 in
 the
 MMR
 study,
 the
 study
 looked
 
at
 all
 of
 the
 leading
 causes
 of
 death
 for
 women
 of
 reproductive
 age
 (WRA)
 in
 Nepal.
 
 
The
 following
 table
 outlines
 the
 leading
 causes
 of
 death
 of
 WRA.
 

 
Table
 2:
 Top
 20
 leading
 single
 causes
 of
 death
 of
 women
 of
 reproductive
 age
 in
 
Nepal,
 2008-­‐2009
36

 
Ranking
  Cause
 of
 Death
  Number
  Percent
 
1
  Suicide
  240
  16.0
 
2
  Accidents
  135
  9.0
 
3
  Tuberculosis
  76
  5.1
 
4
  Malignant
 
neoplasm
 of
 uterus,
 
part
 unspecified
 
59
  3.9
 
5
  Fever
 of
 unknown
 
origin
 
58
  3.9
 
6
  Other
 chronic
 
obstructive
 
pulmonary
 disease
 
57
  3.8
 
7
  Stroke,
 not
 
specified
 as
 
hemorrhage
 or
 
infarction
 
 
50
  3.3
 
8
  Abdominal
 and
 
pelvic
 pain
 
42
  2.8
 
9
  Diarrhea
 &
 
gastroenteritis
 of
 
presumed
 
infectious
 origin
 
 
41
  2.7
 

 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
36

 Suvedi,
 et
 al.
 2009.
 “Nepal
 Maternal
 Mortality
 and
 Morbidity
 Study
 2008/2009:
 
Summary
 of
 Preliminary
 Findings.”
 Family
 Health
 division,
 Department
 of
 Health
 
Services,
 Ministry
 of
 Health,
 Government
 of
 Nepal.
 2009.
 Kathmandu,
 Nepal.
 Table
 5:
 
 
Top
 twenty
 leading
 single
 causes
 of
 death
 of
 women
 of
 reproductive
 ago.
 Page
 8.
 

 

 
31
 

 
Table
 2,
 Continued
 

 
9
  Heart
 Disease
  41
  2.7
 
11
  Hemorrhage
 
(antepartum
 and
 
postpartum)
 
37
  2.5
 
12
  Eclampsia
  35
  2.3
 
12
  Unspecified
 
Jaundice
 
34
  2.3
 
14
  Unspecified
 renal
 
failure
 
31
  2.1
 
15
  Other
 maternal
 
diseases
 
classifiable
 
elsewhere
 but
 
complicating
 
pregnancy,
 
childbirth
 and
 
peuroerium
 
28
  1.9
 
16
  Toxic
 effect
 of
 
contact
 with
 
venomous
 animals
 
27
  1.8
 
17
  Fibrosis
 and
 
cirrhosis
 of
 liver
 
25
  1.7
 
18
  Other
 pulmonary
 
heart
 disease
 
 
23
  1.5
 
18
  Maternal
 infectious
 
&
 parasitic
 
diseases
 
23
  1.5
 
Nepal
 Maternal
 Mortality
 and
 Morbidity
 Study
 2008/2009
 

 
When
 the
 author
 of
 this
 thesis
 conducted
 her
 research,
 she
 expected
 to
 
encounter
 many
 of
 the
 findings
 regarding
 women’s
 health,
 and
 specifically
 maternal
 
health,
 in
 Nepal.
 
 However,
 she
 was
 surprised
 to
 discover
 that
 the
 leading
 cause
 of
 
death
 of
 WRA
 was
 suicide,
 at
 16
 percent
37
.
 This
 was
 a
 steep
 increase
 from
 a
 previous
 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
37

 Suvedi,
 et
 al.
 2009.
 “Nepal
 Maternal
 Mortality
 and
 Morbidity
 Study
 2008/2009:
 
Summary
 of
 Preliminary
 Findings.”
 Family
 Health
 division,
 Department
 of
 Health
 

 

 
32
 

 
MMR
 study
 from
 1998,
 when
 it
 was
 ranked
 third
 at
 10
 percent.
 
 This
 highlights
 the
 
urgent
 need
 for
 attention
 to
 this
 issue.
 
 Unfortunately,
 not
 much
 is
 known
 about
 the
 
causes
 of
 and
 reasons
 for
 suicide
 in
 these
 cases,
 and
 since
 it
 was
 first
 acknowledged
 
as
 a
 problem
 in
 1998,
 no
 long-­‐range
 studies
 have
 identified
 ways
 to
 address
 it.
 
 
Significant
 amounts
 of
 research
 must
 be
 conducted
 to
 gain
 a
 better
 understanding
 of
 
what
 might
 lead
 a
 young
 woman
 in
 Nepal
 to
 commit
 suicide.
 
 The
 Maternal
 Mortality
 
and
 Morbidity
 Study
 may
 have
 provided
 some
 brief
 insights
 into
 the
 mentality
 
behind
 such
 actions.
 
 For
 example,
 21-­‐year-­‐old
 Sanju
38

 was
 found
 in
 her
 bedroom
 
after
 taking
 medicine
 prescribed
 to
 kill
 lice.
 
 Since
 lice
 is
 a
 common
 problem,
 no
 one
 
questioned
 how
 she
 acquired
 the
 medicine.
 
 She
 was
 illiterate
 and
 pregnant
 for
 the
 
third
 time.
 
 Her
 family
 took
 her
 to
 the
 hospital,
 a
 25-­‐minute
 journey.
 
 She
 was
 
immediately
 admitted
 to
 the
 facility
 and
 attended
 to,
 but
 died
 a
 few
 hours
 after
 
arrival.
 
 According
 to
 a
 female
 community
 health
 volunteer,
 Sanju
 suffered
 from
 
hysteria
 and
 was
 forced
 into
 an
 affair
 with
 her
 father-­‐in-­‐law.
 
 Although
 she
 was
 
treated
 for
 hysteria,
 her
 affair
 continued.
 
 It
 is
 widely
 believed
 that
 this
 is
 the
 reason
 
she
 committed
 suicide
39
.
 
 Considering
 the
 rate
 of
 suicide
 for
 WRA,
 and
 especially
 
considering
 the
 rate
 of
 increase
 since
 the
 last
 study,
 it
 is
 apparent
 that
 research
 to
 
better
 understand
 the
 causes
 leading
 to
 such
 a
 high
 suicide
 rate
 needs
 to
 be
 done,
 to
 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Services,
 Ministry
 of
 Health,
 Government
 of
 Nepal.
 2009.
 Kathmandu,
 Nepal.
 Table
 5:
 
Top
 twenty
 leading
 single
 causes
 of
 death
 of
 women
 of
 reproductive
 ago.
 Page
 8.
 
38

 All
 the
 names
 of
 people
 included
 have
 been
 changed
 to
 protect
 them.
 
 
 
39

 Suvedi,
 et
 al.
 2009.
 “Nepal
 Maternal
 Mortality
 and
 Morbidity
 Study
 2008/2009:
 
Summary
 of
 Preliminary
 Findings.”
 Family
 Health
 division,
 Department
 of
 Health
 
Services,
 Ministry
 of
 Health,
 Government
 of
 Nepal.
 Case
 Study:
 Suicide
 of
 a
 Pregnant
 
Woman.
 2009.
 Kathmandu,
 Nepal.
 Page
 9.
 

 

 
33
 

 
take
 control
 of
 the
 issue.
 
 Until
 then,
 however,
 the
 best
 that
 can
 be
 done
 is
 to
 provide
 
counseling
 through
 facilities,
 which
 may
 serve
 as
 a
 sanctuary
 away
 from
 women’s
 
domestic
 troubles.
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
34
 

 
Chapter
 Twelve:
 Health
 Care
 for
 Immigrants
 
Another
 issue
 that
 cannot
 be
 ignored
 is
 the
 issue
 of
 health
 care
 for
 immigrants
 
in
 Nepal.
 
 Women
 have
 had
 a
 difficult
 history
 in
 Nepal
 and
 the
 surrounding
 countries.
 
 
Because
 of
 the
 turmoil
 in
 Tibet,
 many
 people
 have
 fled
 to
 neighboring
 Nepal,
 to
 
escape
 the
 pressure
 from
 China.
 
 Since
 the
 Tibetan
 uprising
 in
 1959,
 during
 which
 
the
 14
th

 Dalai
 Lama
 and
 many
 members
 of
 his
 government
 fled
 to
 India,
 over
 100,000
 
Tibetans
 fled
 in
 a
 mass
 exodus
 to
 the
 neighboring
 countries
 of
 India,
 Nepal
 and
 
Bhutan
 as
 well
 as
 other
 countries
 around
 the
 world
 like
 the
 United
 States
 and
 
Switzerland
40
.
 
 This
 massive
 emigration
 is
 known
 as
 the
 Tibetan
 Diaspora.
 
 King
 
Mahendra
 defied
 Chairman
 Mao
 and
 granted
 the
 refugees
 protection.
 
 In
 1960,
 the
 
King
 even
 gave
 two
 settlements,
 Jawalakhel
 and
 Jorpat,
 to
 the
 Tibetans
 as
 royal
 gifts
 
from
 the
 Palace
41
.
 
 Although
 most
 of
 the
 Tibetans
 travel
 to
 India,
 over
 14,000
 reside
 
in
 Nepal.
 
 Even
 today,
 thousands
 of
 people
 continue
 to
 flee
 in
 search
 of
 a
 better
 life.
 
According
 to
 Maura
 Moynihan,
 author
 of
 “Tibetans
 in
 Nepal:
 The
 Lost
 
Sanctuary,”
 the
 Tibetan
 people
 living
 in
 Nepal
 are
 split
 into
 two
 groups:
 the
 ones
 who
 
arrived
 prior
 to
 1989
 and
 the
 ones
 who
 arrived
 after.
 
 For
 many
 decades,
 Tibetans
 
were
 treated
 well
 in
 Nepal—they
 opened
 shops
 and
 restaurants
 and
 were
 successful
 
industrialists,
 building
 carpet
 factories.
 
 
 However,
 In
 1998,
 
 the
 Nepali
 Government
 
stopped
 issuing
 RCs
 (Refugee
 Cards)
 to
 Tibetans
 born
 in
 Nepal
 after
 1989.
 
 Without
 a
 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
40

 Dowman,
 Keith.
 “The
 Tibetan
 Diaspora
 and
 Tibetan
 Buddhism
 in
 the
 West.”
 The
 
Sacred
 Life
 of
 Tibet,
 HarperCollins,
 1997.
 
http://www.keithdowman.net/essays/diaspora.htm
 
41

 Moynihan,
 Maura.
 “Tibetans
 in
 Nepal:
 The
 Lost
 Sanctuary.”
 Rangzen
 Alliance.
 
http://www.rangzen.net/2012/04/05/tibetans-­‐in-­‐nepal-­‐the-­‐lost-­‐sanctuary/
 

 

 

 
35
 

 
Refugee
 Card,
 Tibetans
 struggle
 to
 find
 employment,
 education
 and
 basic
 civil
 
liberties
 like
 hanging
 images
 of
 HH
 Dalai
 Lama
 in
 a
 business
 or
 hotel
 lobby.
 The
 
refugees
 who
 arrived
 in
 or
 were
 born
 in
 Nepal
 before
 1989
 are
 allowed
 to
 stay
 in
 the
 
country
 with
 their
 families,
 but
 are
 given
 little
 else.
 
 They
 have
 limited
 economic
 and
 
political
 rights.
 
 The
 more
 recently
 arrived
 Tibetans
 are
 technically
 illegal
 aliens.
 
 All
 
of
 them,
 however,
 are
 treated
 as
 social
 outcasts,
 receiving
 little
 to
 no
 health
 care.
 
 
This
 is
 another
 issue
 in
 the
 broader
 scale
 of
 maternal
 health
 care
 that
 needs
 to
 be
 
addressed—the
 care
 of
 immigrants.
 

 

 

 

 

 

 

 

 

 

 

 

 

 
36
 

 
Chapter
 Thirteen:
 Infant
 Mortality
 
 
Around
 the
 world,
 eight
 out
 of
 ten
 women
 will
 suffer
 the
 loss
 of
 a
 child.
 
 This
 
statistic,
 from
 Save
 the
 Children,
 emphasizes
 the
 need
 to
 address
 the
 proper
 care
 and
 
medical
 treatment
 of
 children
42
.
 
 In
 Nepal,
 this
 need
 is
 even
 more
 apparent.
 
 The
 
country
 ranks
 139
th
 

 in
 infant
 mortality
 at
 38.71
 percent,
 according
 to
 The
 United
 
Nations
 World
 Population
 Prospects
 report
43
.
 
 According
 to
 a
 WHO
 study,
 the
 under-­‐
5
 mortality
 rate
 in
 1998
 in
 South
 Eastern
 Asia
 was
 second
 highest
 globally
 only
 to
 
Africa.
 
 However,
 by
 2008,
 it
 had
 dipped
 below
 the
 world
 average,
 landing
 in
 third
 
place
 behind
 the
 African
 and
 the
 Eastern
 Mediterranean
 Regions.
 
 This
 is
 most
 likely
 
due
 to
 an
 increase
 in
 child
 health
 interventions
 around
 the
 world,
 such
 as
 the
 use
 of
 
insecticide-­‐treated
 nets
 to
 prevent
 malaria,
 prevention
 of
 mother-­‐to-­‐child
 
transmission
 of
 HIV,
 and
 vaccinations
 against
 Hepatitis
 B
 and
 Haemophilus
 influenza
 
type
 B
 pneumonia.
 
 Haemophilus
 influenza
 type
 B
 pneumonia,
 or
 Hib,
 is
 a
 bacterium
 
estimated
 to
 be
 responsible
 for
 3
 million
 serious
 illnesses
 and
 386,000
 deaths
 each
 
year.
 
 Children
 between
 the
 ages
 of
 18
 months
 and
 four
 years
 are
 most
 vulnerable,
 
but
 almost
 all
 victims
 are
 under
 five
 years.
 Despite
 what
 its
 name
 suggests,
 Hib
 does
 
not
 cause
 influenza,
 and
 although
 Hib
 meningitis
 is
 a
 serious
 disease,
 Hib
 pneumonia
 
causes
 more
 deaths
 than
 the
 meningitis
 version.
 Fortunately,
 Hib
 is
 very
 preventable,
 
and
 a
 vaccine
 has
 been
 available
 in
 developed
 countries
 since
 the
 early
 1990s,
 yet
 
according
 to
 World
 Health
 Organization,
 approximately
 386,000
 children
 still
 die
 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
42

 Statistic
 acquired
 from
 Save
 the
 Children
 LA’s
 Mother’s
 Day
 Roundtable
 Luncheon,
 
May
 10,
 2012.
 
43

 “World
 Population
 Prospects.”
 United
 Nations
 Department
 of
 Economic
 and
 Social
 
Affairs.
 28
 June
 2011.
 http://esa.un.org/unpd/wpp/Excel-­‐Data/mortality.htm
 

 

 
37
 

 
each
 year
 from
 it
44
.
 
 The
 main
 reasons
 for
 the
 lack
 of
 the
 vaccines
 in
 developing
 
countries
 is
 the
 limited
 access
 to
 
 information
 about
 the
 disease
 and
 the
 vaccine,
 and
 
lack
 of
 money.
 
 Hib
 is
 a
 silent
 disease,
 claiming
 most
 victims
 without
 even
 being
 
recognized;
 therefore,
 understanding
 (and
 thus
 treating)
 it
 is
 incredibly
 difficult
 for
 
the
 uninformed.
 
 Furthermore,
 the
 cost
 of
 the
 vaccine
 is
 approximately
 seven
 times
 
more
 than
 the
 cost
 of
 common
 childhood
 vaccines against
 measles,
 polio,
 
tuberculosis,
 diphtheria,
 tetanus,
 and
 pertussis
45
.
 
 This
 poses
 a
 very
 tricky
 problem:
 
governments
 may
 not
 want
 to
 spend
 the
 money
 on
 it
 unless
 there
 is
 sufficient
 proof
 
that
 it
 will
 work.
 
According
 to
 source,
 Hib
 strikes
 like
 many
 other
 contagious
 diseases.
 
 Once
 it
 
is
 contracted,
 it
 settles
 in
 the
 nose
 or
 throat
 and
 is
 transferred
 in
 little
 droplets
 
through
 exhalation.
 
 Most
 often,
 Hib
 enters
 into
 the
 bloodstream
 and
 travels
 to
 the
 
lungs
 causing
 pneumonia,
 but
 occasionally
 it
 travels
 to
 the
 brain
 and
 spinal
 cord,
 
causing
 meningitis.
 
 However,
 the
 symptoms
 of
 Hib
 are
 like
 several
 other
 illnesses,
 so
 
it
 is
 difficult
 to
 identify
46
.
 
 Fortunately,
 industrialized
 countries
 became
 aware
 of
 Hib
 
and
 the
 many
 dangers
 it
 presents
 over
 50
 years
 ago.
 
 As
 of
 2004,
 89
 countries
 
provided
 Hib
 vaccines
 to
 infants.
 
 In
 2002,
 Malaysia
 became
 the
 first
 Asian
 country
 to
 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
44

 Haemophilus
 influenza
 type
 B
 (HiB)
 Fact
 Sheet.
 World
 Health
 Organization.
 
http://www.who.int/mediacentre/factsheets/fs294/en/index.html.
 December
 2005.
 
45

 Haemophilus
 influenza
 type
 B
 (HiB)
 Fact
 Sheet.
 World
 Health
 Organization.
 
http://www.who.int/mediacentre/factsheets/fs294/en/index.html.
 December
 2005.
 
46

 Department
 of
 Health
 and
 Human
 Services.
 
 Centers
 for
 Disease
 Control
 and
 
Prevention.
 Hib
 Vaccination.
 http://www.cdc.gov/vaccines/vpd-­‐vac/hib/in-­‐short-­‐
adult.htm
 

 

 

 
38
 

 
introduce
 it.
 
 Yet
 the
 hidden
 nature
 of
 Hib
 has
 caused
 countries
 like
 Nepal
 to
 
underestimate
 its
 danger,
 preventing
 them
 from
 providing
 the
 vaccine.
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
39
 

 
Chapter
 Fourteen:
 Under-­‐5
 Mortality
 in
 Nepal
 
Globally,
 childhood
 mortality
 has
 fallen
 over
 the
 last
 two
 decades.
 
 According
 
to
 WHO,
 in
 2008
 (the
 most
 recent
 study
 available),
 the
 global
 mortality
 rate
 of
 
children
 under
 5
 fell
 to
 8.8
 million—down
 30
 percent
 from
 the
 12.4
 million
 
estimated
 in
 1990
47
.
 
 Mortality
 in
 children
 under
 five
 in
 2008
 was
 reported
 at
 65
 per
 
1000
 live
 births,
 down
 27
 percent
 from
 90
 per
 1000
 live
 births
 in
 1990.
 
 Although
 
these
 trends
 are
 encouraging,
 there
 is
 still
 a
 great
 need
 for
 attention
 and
 aid,
 
particularly
 in
 the
 developing
 world.
 
 Undernourishment
 contributes
 to
 one
 third
 of
 
the
 deaths,
 with
 rising
 food
 costs
 and
 falling
 incomes
 cited
 as
 the
 primary
 causes.
 
 In
 
many
 countries,
 the
 number
 of
 undernourished-­‐caused
 deaths
 has
 decreased,
 but
 it
 
has
 actually
 risen
 in
 others.
 
 Currently,
 it
 affects
 nearly
 186
 million
 children
 
worldwide.
 
 The
 following
 chart
 outlines
 the
 decline
 in
 childhood
 mortality
 around
 
the
 world.
 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
47

 “World
 Health
 Statistics.”
 World
 Health
 Organization.
 2010.
 
http://www.who.int/whosis/whostat/EN_WHS10_Full.pdf.
 
 

 

 
40
 

 
Table
 3:
 Mortality
 rate
 in
 children
 under
 5
 by
 WHO
 region
48

 

 

  The
 under-­‐5
 mortality
 rate
 in
 Nepal
 in
 2010
 was
 50,
 down
 from
 141
 in
 
1990.
 
 While
 there
 has
 been
 a
 significant
 decline
 in
 the
 mortality
 rate
 of
 children
 
under
 5,
 including
 in
 the
 South
 Eastern
 Asian
 Region
 (SEAR),
 there
 is
 still
 the
 need
 
for
 attention,
 especially
 in
 Nepal.
 
 Two
 of
 the
 major
 causes
 of
 death
 in
 1-­‐year-­‐olds
 are
 
diarrhea
 and
 pneumonia.
 
 In
 industrialized
 countries
 such
 as
 the
 United
 States,
 cures
 
for
 these
 illnesses
 are
 fairly
 common
 and
 seemingly
 simplistic.
 
 
 For
 diarrhea,
 Oral
 
Rehydration
 Therapy
 (ORT),
 is
 a
 critical
 intervention
 to
 prevent
 dehydration,
 and
 for
 
pneumonia,
 standard
 antibiotics
 usually
 cure
 most
 Acute
 Respiratory
 Infections
 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
48

 “World
 Health
 Statistics.”
 World
 Health
 Organization.
 Figure
 1:
 Mortality
 rate
 in
 
children
 under
 5
 by
 WHO
 region.
 Page
 13.
 2010.
 
http://www.who.int/whosis/whostat/EN_WHS10_Full.pdf.
 
 

 
0
 
20
 
40
 
60
 
80
 
100
 
120
 
140
 
160
 
180
 
200
 
AFR
  AMR
  SEAR
  EUR
  EMR
  WPR
 
1990
 
2008
 

 

 
41
 

 
(ARIs).
 
 However,
 according
 to
 WHO,
 as
 a
 result
 of
 the
 lack
 of
 these
 treatments
 in
 
countries
 like
 Nepal,
 diarrhea
 and
 pneumonia
 contribute
 to
 the
 death
 of
 nearly
 3
 
million
 children
 worldwide
49
.
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
49

 “World
 Health
 Statistics.”
 World
 Health
 Organization.
 
http://www.who.int/whosis/whostat/EN_WHS10_Full.pdf.
 2010.
 

 

 
42
 

 
Chapter
 Fifteen:
 Government
 Aid
 and
 Immunization
 

  The
 Nepali
 government
 has
 made
 a
 concerted
 effort
 to
 reduce
 infant
 mortality
 
over
 the
 past
 several
 years.
 
 As
 of
 2010,
 the
 Infant
 Mortality
 Rate
 (IMR)
 in
 Nepal,
 
which
 is
 calculated
 as
 the
 number
 of
 deaths
 of
 infants
 less
 than
 one
 year
 old
 per
 
1,000
 live
 births,
 was
 38.71,
 a
 drastic
 reduction
 from
 the
 1955
 rate
 of
 210.81.
 
 Even
 
since
 the
 Millennium,
 the
 country
 has
 shown
 increased
 attention
 to
 this
 cause,
 which
 
often
 points
 to
 the
 overall
 health
 of
 a
 country.
 
 As
 recently
 as
 2005,
 for
 example,
 the
 
nation’s
 infant
 mortality
 rate
 was
 54.90
50
.
 
 Across
 the
 country,
 vaccinations
 are
 now
 
provided
 to
 infants
 to
 ensure
 their
 survival,
 which
 is
 likely
 contributing
 to
 these
 
improvements
 in
 IMR.
 

   
 It
 is
 important
 for
 infants
 everywhere
 to
 receive
 vaccinations
 within
 the
 first
 
month
 of
 life.
 
 According
 to
 a
 source,
 the
 Nepali
 government
 previously
 offered
 
vaccines
 against
 the
 most
 deadly
 diseases.
 
 These
 vaccinations
 included
 Bacillus
 
Calmette-­‐Guéin,
 or
 BCG
 which
 protects
 against
 tuberculosis;
 MMR,
 or
 measles,
 
mumps
 and
 rubella;
 TDaP,
 which
 protects
 against
 tetanus,
 diphtheria
 and
 pertussis;
 
and
 the
 polio
 vaccine.
 
 In
 the
 last
 couple
 of
 years,
 however,
 a
 few
 more
 have
 been
 
added
 to
 the
 distribution
 list.
 
 These
 include
 the
 Hepatitis
 B
 vaccine
 and
 the
 
pneumococcal
 vaccine,
 which
 protects
 against
 pneumonia,
 meningitis,
 and
 other
 
bacterial
 infections.
 
 Additionally,
 the
 children
 are
 given
 iron
 tablets
 and
 treatment
 
for
 worms
 to
 prevent
 anemia.
 
 The
 distribution
 of
 these
 vaccines
 is
 very
 promising,
 
with
 hopes
 to
 eliminate
 the
 main
 causes
 of
 infant
 mortality.
 
 However,
 according
 to
 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
50

 “World
 Population
 Prospects:
 The
 2010
 Revision.”
 United
 Nations,
 Department
 of
 
Economic
 and
 Social
 Affairs,
 Population
 Division
 (2011),
 CD-­‐ROM
 Edition
 

 

 
43
 

 
the
 Rupakot
 Health
 Post
 workers
 in
 the
 Lamjung
 Valley
 in
 Nepal,
 pneumonia
 is
 still
 
one
 of
 the
 two
 leading
 causes
 of
 death
 in
 infants.
 
 There
 is
 a
 major
 gap
 between
 the
 
statistics
 of
 the
 distribution
 of
 these
 vaccines
 and
 resulting
 survival
 rates.
 
 This
 
problem
 likely
 falls
 on
 the
 execution
 of
 the
 communication
 strategies
 for
 the
 
vaccination
 clinics
 around
 the
 country.
 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
44
 

 
Chapter
 Sixteen:
 Clean
 Home
 Delivery
 Kits
 

  A
 key
 element
 in
 preventing
 infant
 mortality,
 as
 well
 as
 potentially
 fatal
 
infections
 in
 the
 mother,
 is
 clean
 delivery.
 
 In
 other
 words,
 ensuring
 that
 the
 baby
 is
 
born
 in
 a
 sterile
 environment
 using
 sterile
 tools
 to
 eliminate
 the
 chance
 of
 infection.
 
 
There
 has
 been
 a
 massive
 movement
 by
 governmental
 and
 non-­‐governmental
 
organizations
 in
 developing
 countries
 for
 safe
 motherhood
 programs
 and
 a
 major
 
push
 for
 hygienic
 birthing
 environments.
 
 In
 an
 interview
 with
 Bimala
 Poudel,
 the
 
midwife
 at
 Rupakot
 Health
 Post,
 Mrs.
 Poudel
 noted
 that
 home
 deliveries
 have
 a
 
significantly
 lower
 chance
 of
 a
 positive
 outcome
 than
 hospital
 deliveries.
 
 The
 
primary
 reason,
 she
 said,
 was
 because
 of
 bleeding
 and
 infection
51
.
 
 Infection
 is
 
usually
 caused
 by
 the
 lack
 of
 cleanliness
 of
 the
 birthing
 environment,
 which
 in
 these
 
villages,
 is
 extremely
 unhygienic.
 
 
 Many
 women
 deliver
 on
 straw
 mats
 that
 are
 used
 
throughout
 their
 houses,
 and
 which
 often
 have
 cow
 dung
 embedded
 into
 the
 straw.
 
 
Infections
 are
 a
 major
 cause
 of
 Nepali
 infant
 deaths
 in
 the
 first
 29
 days
 of
 life,
 a
 very
 
critical
 period
52
.
 
 Prevention
 of
 infection
 during
 delivery
 and
 immediately
 after
 birth
 
is
 therefore
 of
 paramount
 importance.
 
 
 

  Clean
 Home
 Delivery
 Kits
 (CHDK)
 are
 an
 affordable
 and
 accessible
 solution
 to
 
the
 unhygienic
 delivery
 practices
 in
 many
 rural
 areas
 of
 the
 world.
 
 In
 Nepal,
 
Maternal
 and
 Child
 Health
 Products,
 Ltd.
 (MDHP)
 has
 developed
 a
 disposable
 clean
 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
51

 Poudel,
 Bimala,
 RHP
 Midwife.
 Personal
 Interview.
 Rupakot,
 Nepal,
 April
 16,
 2012.
 
52

 Sinha,
 Kounteya,
 TNN.
 “70%
 of
 infant
 deaths
 within
 30
 days
 of
 birth.”
 
 Times
 of
 
India.
 3
 April
 2012.http://articles.timesofindia.indiatimes.com/2012-­‐04-­‐
03/india/31280541_1_neonatal-­‐mortality-­‐neonatal-­‐deaths-­‐mortality-­‐rate
 

 

 

 
45
 

 
delivery
 kit,
 although
 the
 concept
 has
 been
 around
 for
 much
 longer,
 with
 health
 care
 
workers
 identifying
 its
 predecessors
 going
 back
 at
 least
 10
 years.
 
 The
 kit
 addresses
 
four
 of
 the
 six
 clean
 delivery
 principles
 defined
 by
 World
 Health
 Organization
 
(WHO),
 which
 states
 that
 “the
 use
 of
 simple,
 disposable
 delivery
 kits
 will
 help
 
achieve
 as
 clean
 a
 delivery
 as
 possible”
53
.
 
 At
 approximately
 US$0.40,
 the
 kits
 contain
 
a
 sterile
 blade
 for
 cutting
 the
 umbilical
 cord;
 a
 plastic
 sheet
 on
 which
 to
 deliver
 the
 
baby;
 a
 plastic
 coin
 to
 provide
 a
 clean
 surface
 against
 which
 to
 cut
 the
 cord;
 a
 clean
 
string
 to
 tie
 off
 the
 cord,
 and
 soap
 to
 ensure
 proper
 hygiene
 of
 the
 mother
 and
 her
 
attendant
 during
 the
 delivery.
 

  According
 to
 a
 study
 conducted
 in
 1998
 by
 the
 Program
 for
 Appropriate
 
Technology
 in
 Health
 (PATH)
 and
 Save
 the
 Children-­‐U.S.,
 use
 of
 the
 CHDK
 reduced
 
birth-­‐associated
 infection
 by
 half
54
.
 
 The
 kits
 can
 be
 used
 to
 encourage
 a
 cultural
 shift
 
toward
 education.
 
 Mortality
 rates
 and
 culturally-­‐adapted
 health-­‐promotion
 
programs
 including
 the
 single-­‐use
 births
 kits
 and
 hygiene
 education
 can
 dramatically
 
reduce
 the
 mortality
 rates
 and
 neonatal
 tetanus
 rates.
 
 It
 is
 important
 to
 note
 that
 the
 
education
 that
 accompanies
 the
 distribution
 of
 the
 kits
 is
 essential
 to
 the
 success
 of
 
the
 kits.
 
 A
 major
 obstacle
 that
 health
 care
 workers
 face
 in
 rural
 villages
 relates
 to
 
language
 and
 cultural
 barriers.
 
 Additionally,
 the
 Nepali
 government
 is
 inhibiting
 the
 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
53

 “Simple
 kits
 save
 lives:
 Clean-­‐delivery
 supplies
 help
 women
 and
 newborns
 avoid
 
infection
 during
 home.”
 PATH.
 http://www.path.org/projects/clean-­‐delivery_kit.php
 
54

 Seward,
 Nadine,
 et
 al.
 “Association
 between
 Clean
 Delivery
 Kit
 Use,
 Clean
 Delivery
 
Practices,
 and
 Neonatal
 Survival:
 Pooled
 Analysis
 of
 Data
 from
 Three
 Sites
 in
 South
 
Asia.”
 Public
 Library
 of
 Science:
 Medicine.
 28
 February
 2012.
 
http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.10
01180#s3
 

 

 
46
 

 
distribution
 of
 the
 kits;
 
 because
 the
 government
 encourages
 hospital
 births,
 there
 is
 
concern
 that
 providing
 pregnant
 women
 with
 home
 delivery
 kits
 might
 convey
 the
 
misconception
 that
 the
 kits
 are
 just
 as
 effective.
 
 The
 key
 is
 communicating
 the
 
benefit
 of
 the
 kits,
 while
 still
 emphasizing
 that
 a
 hospital
 delivery
 is
 the
 best
 option.
 
 
For
 this
 reason,
 the
 proper
 communication
 of
 the
 importance
 of,
 and
 use
 of,
 the
 kits
 
is
 necessary.
 
 
 

  In
 any
 country,
 language
 and
 cultural
 differences
 can
 inhibit
 successful
 
communication,
 but
 the
 author
 found
 that
 in
 Nepal,
 this
 problem
 is
 present
 especially
 
in
 the
 rural
 villages—where
 help
 is
 most
 needed.
 
 In
 a
 study
 published
 in
 The
 Lancet
 
in
 February,
 2012,
 researchers
 in
 Pakistan
 and
 Bangladesh
 found
 that
 by
 cleaning
 the
 
cut
 umbilical
 cord
 with
 an
 antiseptic
 called
 chlorhexidine,
 the
 mortality
 rate
 was
 
reduced
 by
 38
 percent
55
.
 
 In
 Nepal,
 a
 previous
 study
 testing
 the
 results
 of
 using
 
chlorhexidine
 showed
 it
 reduced
 infection
 rates
 by
 about
 75
 percent,
 and
 reduced
 
deaths
 by
 24
 percent.
 
 Using
 an
 antiseptic
 in
 the
 birth
 setting
 could
 be
 a
 very
 simple
 
way
 to
 save
 lives;
 however,
 many
 people
 in
 these
 countries
 are
 resistant
 to
 these
 
solutions.
 
 
 

  In
 rural
 areas
 of
 Nepal,
 however,
 cow
 dung
 is
 rubbed
 on
 the
 cut
 cord
 and
 open
 
wounds
 because
 it
 is
 believed
 to
 contain
 special
 healing
 properties.
 
 Unfortunately,
 
the
 result
 is
 usually
 infection
 and
 often
 death.
 
 Challenging
 the
 widely
 held
 spiritual
 
beliefs
 will
 likely
 prove
 futile,
 especially
 when
 the
 town
 elders
 place
 pressure
 on
 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
55

 Darmstadt,
 Gary,
 and
 Saul
 Morris
 and
 Wendy
 Prosser.
 “Cutting
 the
 Cord:
 A
 New
 
Way
 To
 Save
 Newborn
 Lives.”
 Impatient
 Optimists:
 Bill
 &
 Melinda
 Gates
 Foundation.
 
http://www.impatientoptimists.org/Posts/2012/02/Cutting-­‐the-­‐Cord-­‐A-­‐New-­‐Way-­‐
to-­‐Save-­‐Newborn-­‐Lives.
 8
 February
 2012.
 

 

 
47
 

 
young
 mothers
 to
 resort
 to
 the
 ancient
 practices.
 
 While
 interviewing
 women
 in
 
Rupakot,
 the
 author
 discovered
 that
 one
 young
 mother
 stopped
 giving
 her
 asthmatic
 
child
 an
 inhaler
 from
 an
 American
 doctor
 when
 an
 elder
 chastised
 her.
 
 Similarly,
 the
 
villagers
 believe
 that
 even
 in
 40°
 C
 (104°
 F)
 weather,
 a
 child
 should
 wear
 their
 
heaviest
 clothes,
 including
 a
 sweatshirt
 and
 socks,
 to
 prevent
 illness.
 
 Although
 this
 
can
 cause
 heat
 rash,
 the
 villagers’
 solution
 is
 to
 apply
 baby
 powder
 and
 for
 the
 child
 
to
 continue
 wearing
 the
 heavy
 clothes,
 which
 contradicts
 Western
 concepts
 of
 
treatment
 for
 this
 problem.
 
 These
 are
 just
 a
 few
 of
 the
 examples
 of
 commonly
 held
 
beliefs
 discovered
 by
 the
 author
 that
 likely
 hinder
 the
 progress
 of
 successful
 medical
 
practices.
 

  To
 reduce
 the
 infant
 and
 maternal
 mortality
 in
 countries
 like
 Nepal,
 it
 will
 be
 
necessary
 to
 work
 with
 and
 respect
 the
 beliefs
 of
 the
 culture.
 
 Fortunately,
 many
 of
 
the
 younger
 mothers
 appear
 to
 be
 more
 open
 to
 Western
 practices.
 
 The
 Nepali
 
government
 has
 initiated
 a
 1,000
 Nepali
 Rupee
 incentive
 to
 deliver
 in
 a
 hospital—
which
 calculates
 to
 approximately
 $12.00,
 over
 a
 week’s
 worth
 of
 income
 for
 most
 
families.
 
 This
 incentive
 signifies
 just
 one
 effort
 by
 the
 government
 to
 reduce
 infant
 
and
 maternal
 mortality
 by
 encouraging
 births
 in
 a
 more
 hygienic,
 controlled
 location.
 

 

 

 

 

 

 

 
48
 

 
Chapter
 Seventeen:
 International
 Efforts
 
Many
 organizations,
 both
 governmental
 and
 non-­‐governmental,
 have
 
established
 programs
 and
 initiatives
 to
 combat
 global
 infant
 and
 maternal
 mortality.
 
 
One
 highly
 respected
 program
 developed
 by
 the
 United
 Nations
 –The
 United
 Nations
 
Millennium
 Development
 Goals
 (UNMDGs),
 highlights
 a
 set
 of
 eight
 goals
 that
 193
 UN
 
members
 have
 agreed
 to
 achieve
 by
 the
 year
 2015.
 
 The
 aim
 of
 these
 goals
 is
 to
 
encourage
 development
 by
 improving
 the
 social
 and
 economic
 conditions
 in
 the
 
world’s
 poorest
 countries.
 
 The
 United
 Nations
 has
 outlined
 the
 UNMDGs
 on
 their
 
official
 website:
 
UNMDGs
 
Eradicating
 extreme
 poverty
 continues
 to
 be
 one
 of
 the
 main
 
challenges
 of
 our
 time,
 and
 is
 a
 major
 concern
 of
 the
 
international
 community.
 Ending
 this
 scourge
 will
 require
 the
 
combined
 efforts
 of
 all,
 governments,
 civil
 society
 organizations
 
and
 the
 private
 sector,
 in
 the
 context
 of
 a
 stronger
 and
 more
 
effective
 global
 partnership
 for
 development.
 The
 Millennium
 
Development
 Goals
 set
 time
 bound
 targets,
 by
 which
 progress
 
in
 reducing
 income
 poverty,
 hunger,
 disease,
 lack
 of
 adequate
 
shelter
 and
 exclusion
 —
 while
 promoting
 gender
 equality,
 
health,
 education
 and
 environmental
 sustainability
 —
 can
 be
 
measured.
 They
 also
 embody
 basic
 human
 rights
 —
 the
 rights
 of
 
each
 person
 on
 the
 planet
 to
 health,
 education,
 shelter
 and
 
security.
 The
 Goals
 are
 ambitious
 but
 feasible
 and,
 together
 
with
 the
 comprehensive
 United
 Nations
 development
 agenda,
 
set
 the
 course
 for
 the
 world’s
 efforts
 to
 alleviate
 extreme
 
poverty
 by
 2015.
 —United
 Nations
 Secretary-­‐General
 BAN
 Ki-­‐
moon
56

 

 
Unfortunately,
 gaining
 the
 support
 of
 Americans
 in
 fulfilling
 the
 UNMDGs
 might
 be
 
difficult.
 
 In
 an
 anonymous,
 convenience-­‐sampled
 online
 survey
 of
 100
 people
 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
56

 “Millennium
 Development
 Goals.”
 United
 Nations.
 
http://www.un.org/millenniumgoals/bkgd.shtml
 

 

 
49
 

 
conducted
 in
 January
 2012
 by
 the
 author,
 only
 35
 percent
 of
 respondents
 said
 that
 
they
 were
 familiar
 with
 the
 geographic
 location
 of
 Nepal,
 and
 70
 percent
 were
 
unaware
 of
 the
 country’s
 political
 and
 cultural
 circumstances.
 
 Fortunately,
 however,
 
most
 of
 the
 respondents
 were
 sympathetic
 to
 the
 causes
 of
 NGOs
 seeking
 to
 better
 
the
 lives
 of
 those
 in
 3
rd

 world
 countries.
 
 94
 percent
 of
 respondents
 said
 that
 they
 
were
 compelled
 to
 give
 to
 charities,
 and
 98
 percent
 believed
 that
 the
 health
 care
 in
 
developing
 countries
 is
 insufficient.
 
 According
 to
 the
 Blackbaud
 Index
 of
 Charitable
 
Giving,
 overall
 charitable
 revenues
 in
 the
 U.S.
 grew
 4.2
 percent
 in
 2011,
 as
 compared
 
to
 2010
57
.
 
 Online
 giving
 has
 increased
 more
 significantly,
 up
 13
 percent
 in
 2011,
 and
 
may
 indicate
 that
 online
 media
 could
 be
 used
 to
 gain
 support,
 which
 will
 hopefully
 
lead
 to
 broader
 interest
 and
 willingness
 to
 donate
 to
 causes
 such
 as
 improving
 
Nepal’s
 child
 and
 maternal
 health.
 
 
Similarly,
 in
 a
 study
 published
 in
 June
 2011,
 Blackbaud
 found
 that
 69
 percent
 
of
 respondents
 donate
 to
 charities
 because
 they
 feel
 a
 personal
 connection
 to
 the
 
cause
58
.
 
 This
 presents
 both
 a
 potential
 threat
 and
 an
 opportunity.
 
 While
 a
 small
 
village
 in
 Nepal
 is
 unfamiliar
 to
 most
 people
 in
 America,
 the
 idea
 of
 giving
 to
 a
 
hospital
 to
 save
 women’s
 and
 children’s
 lives
 is
 universally
 appealing.
 
 However,
 it
 
will
 be
 necessary
 to
 conduct
 more
 targeted
 research
 to
 fully
 understand
 the
 target
 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
57

 “The
 Blackbaud
 Index.”
 Blackbaud.
 Web.
 2012.
 
https://www.blackbaud.com/files/resources/downloads/bbindex_report_may2012.
pdf
 
58

 “The
 Blackbaud
 Index.”
 Blackbaud.
 Web.
 2012.
 
https://www.blackbaud.com/files/resources/downloads/WhitePaper_RunWalkRide
PeerToPeerParticipantSurvey2011.pdf
 

 

 
50
 

 
audiences
 and
 their
 possible
 reasons
 for
 giving,
 and
 to
 develop
 a
 PR
 plan
 aimed
 at
 
encouraging
 the
 sympathy
 and
 support
 of
 American
 donors.
 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
51
 

 
Conclusions
 
1. There
 are
 three
 primary
 conclusions
 that
 can
 be
 drawn
 from
 the
 data
 and
 
analyses
 presented
 in
 this
 thesis.
 
 After
 visiting
 the
 area
 of
 focus,
 rural
 Nepal,
 the
 
author
 is
 able
 to
 offer
 her
 own
 personal
 observations.
 
 The
 first
 conclusion
 is
 the
 
expected
 issues
 inherent
 to
 achieving
 improved
 maternal
 and
 child
 health
 in
 
Nepal.
 
 A
 key
 inhibitor
 as
 observed
 in
 research
 and
 in
 person
 is
 a
 general
 
resistance
 to
 Western
 medicine
 by
 Nepali
 citizens.
 
 This
 resistance
 could
 prove
 
difficult
 to
 work
 through
 given
 the
 accompanying
 language
 barriers,
 cultural
 
differences,
 transportation
 issues,
 religious
 prohibitions
 and
 political
 instability.
 
 
There
 could
 be
 public
 relations
 ramifications
 from
 all
 of
 these
 issues,
 but
 also
 
possible
 public
 relations
 solutions.
 
 
 
a. While
 some
 young
 Nepalis
 are
 sometimes
 taught
 English
 in
 school,
 many
 
are
 not
 educated,
 and
 remain
 illiterate
 in
 their
 own
 native
 language.
 
 This
 
is
 significant
 because
 the
 communication
 and
 dissemination
 of
 
information
 must
 be
 done
 in
 Nepali,
 and
 often
 through
 pictorial
 
representations
 to
 address
 potential
 reading
 comprehension
 issues.
 
 
 
b. Similarly,
 cultural
 differences
 could
 prove
 to
 be
 a
 major
 obstacle
 in
 
communicating
 the
 importance
 of
 modern
 medical
 practices.
 
 As
 described
 
in
 Chapter
 Sixteen:
 Clean
 Home
 Delivery
 Kits,
 proper
 hygiene
 and
 clean
 
delivery
 practices
 are
 essential
 to
 healthy
 mothers
 and
 infants.
 
 However,
 
many
 common
 and
 potentially
 dangerous
 medical
 practices
 are
 deeply
 
rooted
 in
 their
 cultural
 heritage.
 
 It
 is
 arguable
 whether
 one
 should
 

 

 
52
 

 
attempt
 to
 change
 these
 ancient
 practices.
 However,
 one
 thing
 is
 certain:
 
to
 improve
 the
 health
 of
 the
 country,
 changes
 in
 maternal
 birthing
 
practices
 must
 occur,
 and
 will
 likely
 rely
 heavily
 on
 communication
 
strategies
 supporting
 the
 transition.
 
 It
 will
 be
 crucial
 to
 communicate
 the
 
benefit
 of
 Western
 practices
 (including
 the
 importance
 of
 delivering
 in
 a
 
hospital)
 to
 expectant
 mothers,
 while
 still
 respecting
 the
 existing
 beliefs.
 
 
One
 way
 to
 do
 so
 is
 to
 highly
 publicize
 the
 Clean
 Home
 Delivery
 Kits.
 
 For
 
example,
 just
 implementing
 one
 key
 element,
 such
 as
 the
 use
 of
 sterile
 
blades,
 could
 significantly
 lower
 the
 region’s
 infant
 and
 maternal
 mortality
 
rates,
 while
 not
 drastically
 changing
 the
 other
 birthing
 practices
 already
 in
 
place.
 
c. Another
 inhibitor
 relates
 to
 transportation
 issues
 in
 Nepal.
 
 Travelling
 to
 
Nepal
 is
 difficult
 logistically,
 and
 getting
 to
 the
 rural
 villages
 requires
 
extensive
 logistical
 coordination
 as
 well
 as
 individual
 travelers’
 
persistence.
 
 Providing
 staff
 and
 materials
 (including
 instruments,
 large
 
medical
 equipment
 and
 ambulances)
 to
 areas
 like
 Rupakot
 will
 be
 difficult,
 
while
 transporting
 patients
 is
 long
 and
 tiresome,
 and
 can
 even
 worsen
 the
 
patient’s
 condition.
 
 Communication
 will
 be
 essential
 to
 coordinate
 the
 
transportation
 of
 both
 the
 materials
 to
 the
 health
 post
 as
 well
 as
 patients
 
to
 the
 facilities.
 

 

 

 
53
 

 
2. Educating
 poverty-­‐stricken
 areas
 can
 be
 difficult
 in
 any
 country
 but
 may
 be
 
particularly
 so
 in
 Nepal.
 
 Understanding
 the
 unique
 position
 that
 many
 rural
 
villagers
 are
 in
 will
 be
 essential
 to
 properly
 communicating
 with
 them.
 
 Life
 in
 
rural
 Nepal
 is
 very
 different
 from
 anything
 most
 Westerners
 have
 experienced.
 
 
Most
 residents
 do
 not
 have
 access
 to
 running
 water,
 and
 a
 very
 limited
 amount
 of
 
electricity.
 
 Relaying
 messages
 will
 depend
 almost
 entirely
 on
 word-­‐of-­‐mouth
 or
 
basic
 literature.
 
 However,
 any
 literature
 created
 will
 have
 to
 be
 specially
 crafted
 
due
 to
 the
 low
 literacy
 rates.
 
 Pictorial
 representations
 and
 Nepali
 translations
 
will
 be
 key.
 
 It
 will
 also
 be
 essential
 that
 the
 correct
 individuals
 attend
 the
 
information
 sessions
 and
 seminars
 recommended
 below.
 
 Most
 meetings
 in
 small
 
villages
 are
 attended
 solely
 by
 the
 village
 elders,
 who
 are
 almost
 always
 entirely
 
males.
 
 While
 their
 support
 and
 dedication,
 as
 well
 as
 their
 assistance,
 will
 be
 
important,
 the
 key
 audience
 for
 these
 sessions
 is
 women,
 including
 elderly
 
women
 (who
 have
 a
 strong
 influence
 on
 their
 fellow
 residents),
 young
 girls,
 
women
 of
 reproductive
 age,
 pregnant
 women
 and
 mothers.
 
 
 

 
3. With
 the
 political
 instability
 throughout
 the
 country,
 bringing
 personnel
 and
 
materials
 in
 through
 Customs
 in
 Nepal
 could
 also
 prove
 problematic.
 
 It
 is
 
therefore
 absolutely
 essential
 to
 work
 with
 the
 government
 and
 communicate
 the
 
specific
 plans
 for
 Avasar,
 so
 as
 to
 demonstrate
 complete
 cooperation
 and
 avoid
 
any
 potential
 aggravation
 in
 an
 already
 unstable
 government.
 

 

 
54
 

 
Strategic
 Planning
 Model:
 Preparing
 a
 Plan
 for
 Nepal’s
 Fight
 for
 
Maternal/Infant
 Care
 
I. Opportunity
 
 
a. The
 UN
 has
 already
 recognized
 the
 need
 for
 help
 in
 Nepal,
 and
 issues
 
related
 to
 Maternal
 Health
 and
 Child
 Health
 are
 outlined
 as
 some
 of
 its
 
primary
 points
 of
 concern.
 
i. In
 2005,
 500,000
 women
 died
 during
 pregnancy
 or
 childbirth
 
from
 preventable
 causes.
 
 
 
ii. Nepal
 ranks
 139
th

 in
 infant
 mortality
 worldwide,
 with
 an
 infant
 
mortality
 rate
 of
 almost
 39
 percent.
 
II. Business
 Goal
 
a. Decrease
 the
 under-­‐5
 mortality
 rate
 by
 half
 by
 2020.
 
b. Double
 the
 attendance
 at
 local
 infant
 and
 maternal
 clinics
 and
 
educational
 seminars.
 
c. Increase
 awareness
 of
 preventable
 diseases
 
 and
 the
 importance
 of
 
maintaining
 hygienic
 practices
 during
 birth.
 
i. For
 example,
 simple
 practices
 to
 prevent
 illness
 and
 produce
 a
 
healthy
 lifestyle.
 
d. Increase
 awareness
 about
 the
 importance
 of
 nutrition
 and
 taking
 key
 
vitamin
 supplements
 if
 possible.
 
 
e. Increase
 awareness
 about
 the
 proper
 use
 and
 distribution
 of
 vaccines
 
and
 immunizations.
 

 

 
55
 

 
III. SWOT
 Analysis
 
a. Strengths
 
i. Fortunately,
 Avasar
 has
 many
 strengths
 working
 in
 its
 favor,
 the
 
most
 significant
 of
 which
 is
 that
 there
 is
 a
 hospital
 already
 in
 
place.
 
 The
 Lamjung
 Valley
 has
 recently
 built
 a
 hospital,
 
allowing
 Avasar
 to
 bypass
 an
 otherwise
 expensive
 and
 time-­‐
consuming
 step.
 
 
 
ii. Another
 strength
 is
 the
 personnel
 already
 involved
 in
 the
 NGO.
 
 
Avasar
 is
 led
 by
 several
 capable
 people
 from
 Nepal
 and
 the
 
United
 States:
 Nabaraj
 Basaula,
 Katie
 Lillie
 and
 Dr.
 and
 Mrs.
 
Perez-­‐Silva.
 
b. Weaknesses
 
i. Along
 with
 strengths,
 there
 are
 also
 several
 weaknesses
 that
 
will
 likely
 hinder
 Avasar’s
 success.
 
 The
 Lamjung
 Valley
 has
 
access
 to
 extremely
 limited
 resources.
 
 The
 Valley
 is
 poor,
 with
 
few
 residents
 possessing
 any
 Western
 medical
 knowledge
 or
 
experience.
 
 
 
ii. The
 rural
 location
 of
 the
 Valley
 will
 likely
 inhibit
 the
 growth
 of
 
Avasar
 as
 well.
 
 To
 travel
 to
 the
 Valley,
 one
 must
 fly
 first
 to
 
Kathmandu,
 most
 commonly
 through
 Hong
 Kong,
 then
 take
 a
 
small
 plane
 from
 the
 capital
 to
 Pokhara,
 and
 a
 long
 bus
 ride
 to
 
the
 Lamjung
 Valley.
 
 This
 is
 a
 likely
 deterrent
 to
 Americans
 

 

 
56
 

 
interested
 in
 visiting
 or
 volunteering
 to
 offer
 their
 services,
 and
 
makes
 it
 difficult
 to
 transport
 patients
 and
 supplies
 to
 and
 from
 
larger
 cities.
 
 
 
iii. Another
 major
 weakness
 that
 Avasar
 should
 expect
 to
 
encounter
 is
 the
 diversity
 of
 the
 people
 in
 Nepal.
 
 
Fundamentally,
 Nepali
 views,
 especially
 the
 more
 ancient
 views
 
that
 the
 rural
 villagers
 generally
 possess,
 are
 different
 from
 
Western
 views.
 
 These
 cross-­‐cultural
 differences
 will
 likely
 
make
 it
 challenging
 to
 communicate
 with
 the
 people
 of
 Nepal
 
and
 the
 Valley.
 
c. Opportunities
 
i. Perhaps
 the
 greatest
 opportunity
 that
 Avasar
 has
 is
 the
 urgent
 
need
 for
 help
 in
 the
 Valley.
 
 As
 outlined
 by
 the
 UN’s
 Millennium
 
Development
 Goals,
 there
 is
 an
 incredible
 need
 for
 help
 in
 
Nepal,
 specifically
 in
 maternal
 and
 infant
 health
 care.
 
 Also,
 
since
 there
 are
 no
 other
 hospitals
 in
 the
 area,
 and
 the
 nearest
 
city
 is
 hours
 away,
 there
 is
 little
 organized
 competition.
 
 
ii. Fortunately,
 there
 is
 a
 great
 willingness
 of
 people
 around
 the
 
world
 to
 help
 others.
 
 As
 shown
 in
 the
 Blackbaud
 Charitable
 
Giving
 Index,
 the
 altruistic
 efforts
 of
 people
 in
 the
 US
 have
 
grown
 immensely
 in
 the
 past
 few
 years.
 
 The
 author’s
 own
 
online
 survey
 indicated
 that
 many
 people,
 if
 given
 the
 

 

 
57
 

 
opportunity,
 would
 be
 willing
 to
 contribute
 to
 a
 cause
 to
 which
 
they
 feel
 a
 connection.
 
 The
 UNMDG’s
 have
 also
 provided
 
guidelines
 that
 can
 help
 make
 Avasar’s
 efforts
 more
 attainable.
 
 
 
iii. Finally,
 Nepal
 has
 shown
 an
 interest
 in
 bettering
 the
 lives
 of
 its
 
citizens.
 
 Although
 few
 improvements
 may
 be
 visible
 at
 this
 
point,
 the
 government’s
 “five
 year
 plans,”
 campaign
 to
 
encourage
 hospital-­‐based
 births,
 and
 the
 initiation
 of
 the
 
National
 Planning
 Committee
 indicate
 a
 desire
 for
 progress.
 
 
This
 hopefully
 means
 that
 Avasar
 will
 encounter
 little
 
resistance
 from
 the
 government
 in
 pursuing
 the
 NGO’s
 goals.
 
d. Threats
 
i. There
 are
 many
 threats
 that
 are
 very
 likely
 to
 cause
 delays
 and
 
possibly
 hinder
 success.
 
 For
 example,
 political
 upheaval
 and
 
instability
 in
 the
 country
 can
 cause
 many
 problems,
 such
 as
 
safety
 concerns
 for
 visitors
 as
 well
 as
 a
 potentially
 quelling
 
effect
 on
 donations.
 
 Nepal’s
 history
 with
 its
 surrounding
 
countries,
 as
 well
 as
 its
 internal
 struggles,
 could
 significantly
 
inhibit
 the
 progress
 of
 Avasar’s
 cause.
 
 
 
ii. Also,
 there
 are
 many
 cultural
 challenges,
 such
 as
 the
 strict
 
delineation
 between
 the
 castes.
 
 The
 untouchables,
 who
 receive
 
little
 to
 no
 health
 care,
 have
 only
 the
 very
 slimmest
 chance
 of
 
survival
 or
 improvement
 in
 their
 maternal
 health
 and
 survival
 

 

 
58
 

 
rates.
 
 It
 will
 likely
 be
 difficult
 to
 establish
 health
 care
 for
 these
 
people.
 
 The
 inequality
 between
 men
 and
 women
 may
 also
 pose
 
a
 problem.
 
 The
 nature
 of
 the
 author’s
 cause,
 improving
 the
 
quality
 of
 maternal
 and
 infant
 care,
 will
 likely
 be
 difficult
 given
 
the
 few
 rights
 that
 Nepali
 women
 have.
 
 
 
iii. Finally,
 Avasar’s
 biggest
 threat
 might
 be
 from
 charities
 in
 other
 
countries.
 
 Many
 Americans
 feel
 the
 call
 to
 give
 to
 charities
 and
 
causes
 in
 other
 areas,
 and
 while
 there
 is
 a
 definite
 need
 in
 many
 
countries,
 lower
 rates
 of
 donations
 signal
 a
 clear
 lack
 of
 support
 
for
 countries
 like
 Nepal.
 
 
 
Nepal
 is
 a
 beautiful
 country.
 
 The
 people,
 the
 culture
 and
 the
 landscape
 
overwhelm
 every
 sense
 of
 the
 body.
 
 Swathed
 in
 Himalayan
 splendor,
 the
 imposing
 
mountains
 have
 dictated
 the
 political
 and
 cultural
 state
 as
 long
 as
 history
 has
 
recorded.
 
 Over
 the
 last
 several
 decades,
 the
 political
 turmoil
 has
 been
 further
 
heightened,
 and
 the
 Nepali
 people
 are
 looking
 towards
 Western
 civilizations
 for
 a
 
plan
 to
 improve
 their
 health
 and
 accomplish
 these
 changes.
 
 Thankfully,
 public
 
relations
 can
 provide
 important
 communications
 support
 for
 the
 practical
 
implementation
 of
 changes.
 
 Through
 effective
 communications,
 better
 birthing
 
practices
 and
 healthier
 lifestyles
 can
 be
 fully
 executed
 into
 the
 daily
 lives
 of
 the
 
villagers.
 
 These
 changes
 have
 the
 potential
 to
 not
 only
 change
 lives,
 but
 to
 save
 lives.
 
Like
 parents
 everywhere
 around
 the
 world,
 the
 Nepali
 people
 relish
 seeing
 
their
 children
 grow
 up,
 and
 those
 children
 should
 ideally
 expect
 a
 better
 life
 than
 

 

 
59
 

 
their
 parents,
 based
 on
 a
 foundation
 of
 a
 healthier,
 more
 hygienic
 birth
 –
 a
 future
 that
 
could
 very
 well
 be
 possible
 with
 the
 controlled
 execution
 of
 a
 well-­‐developed
 PR
 
plan.
 
 Although
 the
 focus
 of
 this
 thesis
 is
 on
 infant
 and
 maternal
 health
 care
 in
 a
 small
 
village
 in
 Nepal,
 the
 effects
 can
 ripple
 far
 beyond.
 
 As
 former
 United
 States
 President
 
Ronald
 Reagan
 once
 prophetically
 said,
 “We
 cannot
 stop
 at
 the
 foothills
 when
 Everest
 
lies
 ahead.”
59

 
 If
 one
 child’s
 life
 can
 be
 saved,
 why
 can’t
 millions
 be
 saved?
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
59

 http://thinkexist.com/quotes/with/keyword/everest/
 

 

 
60
 

 
Bibliography
 

 
“Aishwarya:
 Nepal's
 forceful
 queen.”
 BBC
 News:
 World
 Edition.
 
http://news.bbc.co.uk/2/hi/south_asia/1369064.stm.
 5
 June
 2001.
 

 
Allen,
 Michael
 and
 S.N.
 Mukherjee,
 eds.
 Women
 in
 India
 and
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 New
 Delhi,
 
Sterling
 Publishers
 Private
 Limited,
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Ashby,
 Jacqueline.
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Rural
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 (1):
 68-­‐79.
 

 
“The
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 2012.
 
https://www.blackbaud.com/files/resources/downloads/bbindex_report_ma
y2012.pdf
 

 
Breiterman,
 Amy
 and
 David
 Hessekiel.
 “Peer
 to
 Peer
 Participant
 Survey.”
 June
 2011.
 
https://www.blackbaud.com/files/resources/downloads/WhitePaper_RunW
alkRidePeerToPeerParticipantSurvey2011.pdf
 

 
Dr.
 Carlough,
 Martha,
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 Personal
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 February,
 2012.
 

 
“Charity
 Trends:
 Top
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 And
 Reasons
 We
 Give.”
 The
 Huffington
 Post.
 5
 January,
 
2012.
 http://www.huffingtonpost.com/2012/01/05/charity-­‐trends-­‐top-­‐5-­‐
wher_n_1184530.html
 

 
“Comparison
 of
 babies
 born
 to
 miscarriages
 in
 the
 Tanahun
 and
 Lamjung
 Valleys
 
from
 2011.”
 
 Statistics
 provided
 by
 Nabaraj
 Basaula,
 January,
 2012.
 

 
Darmstadt,
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 and
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 Morris
 and
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 Prosser.
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 A
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 Way
 
to
 Save
 Newborn
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 Impatient
 Optimists:
 Bill
 &
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http://www.impatientoptimists.org/Posts/2012/02/Cutting-­‐the-­‐Cord-­‐A-­‐
New-­‐Way-­‐to-­‐Save-­‐Newborn-­‐Lives.
 8
 February
 2012.
 

 
Dowman,
 Keith.
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 The
 
Sacred
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http://www.keithdowman.net/essays/diaspora.htm
 

 
“Edmund
 Hillary
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 Thinkexist.com.
 
http://thinkexist.com/quotes/edmund_hillary/
 
“Everest
 Quotes.”
 Thinkexist.com.
 
http://thinkexist.com/quotes/with/keyword/everest/
 

 

 
61
 

 
Figure
 1:
 Mortality
 rate
 in
 children
 under
 5
 by
 WHO
 region.
 “World
 Health
 Statistics.”
 
World
 Health
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“Government
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 National
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 http://www.cbs.gov.np/population_caste.php.
 18
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63
 

 

 
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Sinha,
 Kounteya.
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 M.D.
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 2012.
 

 
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64
 

 
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65
 

 
Appendix
 A:
 Key
 Findings
 from
 Anonymous
 Online
 Survey
 Conducted
 by
 the
 
Author
 

 
-­‐94%
 of
 respondents
 said
 they
 were
 very
 compelled,
 mildly
 compelled
 or
 somewhat
 
compelled
 to
 give
 to
 charities.
 

 
-­‐When
 asked
 if
 they
 believed
 we
 should
 give
 to
 domestic
 causes
 rather
 than
 foreign,
 
66%
 said
 yes.
 

 
-­‐When
 asked
 how
 much
 they
 know
 about
 NGO’s,
 52%
 that
 they
 knew
 “a
 little.”
 
-­‐35%
 of
 the
 participants
 said
 that
 they
 were
 “familiar”
 with
 the
 geographic
 location
 
of
 Nepal
 

 
-­‐70%
 said
 that
 they
 were
 unaware
 of
 the
 political
 and
 cultural
 upheaval
 in
 Nepal.
 
-­‐98%
 said
 that
 they
 believe
 the
 health
 care
 in
 3
rd

 world
 countries
 is
 insufficient.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
66
 

 
Appendix
 B:
 Interview
 with
 Dr.
 Martha
 Carlough
 

 

 
1. There
 are
 many
 other
 countries
 in
 need
 of
 help
 from
 the
 rest
 of
 the
 world.
 
 Why
 
were
 you
 drawn
 to
 Nepal?
 
I
 first
 visited
 Nepal
 as
 a
 medical
 student
 in
 1989.
 At
 that
 time
 it
 had
 the
 3
rd

 
highest
 maternal
 mortality
 rate
 in
 the
 world.
 
2. When
 did
 you
 begin
 your
 efforts
 with
 Nepal?
 
I
 moved
 to
 Nepal
 in
 Jan
 1995,
 and
 returned
 to
 the
 US
 at
 the
 end
 of
 2004.
 
3. In
 your
 opinion,
 what
 is
 the
 one
 thing
 that
 the
 country
 needs
 most?
 
 For
 example,
 
education,
 economic
 stability,
 improved
 health
 care,
 etc.?
 
There
 is
 no
 one
 thing.
 Political
 instability
 and
 economic
 hardship
 have
 
definitely
 affected
 progress
 and
 improvement
 in
 the
 last
 two
 decades.
 
4. Have
 you
 been
 met
 with
 resistance
 from
 the
 Nepali
 government?
 
No.
 I
 worked
 with
 an
 organization
 that
 partnered
 with
 the
 government
 and
 
extended
 their
 work
 in
 ways
 that
 everyone
 could
 agree
 on.
 
5. Is
 the
 government
 supportive
 of
 outside
 efforts?
 
In
 general
 yes,
 though
 most
 government
 officials
 are
 savvy
 enough
 to
 know
 
where
 quick
 money
 is
 available
 from,
 and
 what
 might/might
 not
 be
 
sustainable.
 
 
6. How
 has
 Nepal
 changed
 you?
 
Unfortunately,
 this
 is
 not
 a
 one
 sentence
 answer….after
 a
 decade
 living
 in
 
Nepal,
 I
 left
 a
 piece
 of
 my
 heart
 there
 and
 took
 a
 piece
 of
 Nepal
 with
 me.
 

 

 
67
 

 
7. Do
 you
 think
 it
 is
 important
 to
 send
 US
 doctors
 and
 nurses
 to
 Nepal?
 
No.
 I
 don’t
 think
 sending
 is
 the
 answer.
 I
 think
 partnering
 with
 sustainable,
 
integrated
 systems
 of
 care
 and
 education
 is.
 Too
 many
 short-­‐term
 fixes
 and
 
unintegrated
 programs/projects,
 even
 if
 well
 intentioned,
 have
 failed.
 
 
8. Have
 you
 seen
 improvements
 over
 the
 last
 several
 years?
 
Yes,
 would
 also
 suggest
 reading
 stats
 on
 this.
 Nepal
 has
 cut
 its
 maternal
 
mortality
 rate
 in
 half
 in
 15
 years
 despite
 poverty,
 political
 strife
 and
 
continued
 lack
 of
 access
 to
 care
 in
 rural
 areas.
 
9. Do
 you
 think
 that
 the
 Nepali
 people
 are
 open
 to
 Western
 medicine
 and
 traditions?
 
There
 is
 not
 one
 Nepali
 people
 as
 it
 is
 an
 enormously
 ethnic
 and
 religiously
 
diverse
 landscape.
 
10. Is
 the
 language
 barrier
 difficult?
 
 
Nepali
 is
 not
 a
 difficult
 language
 to
 learn,
 but
 obviously
 for
 short-­‐term
 work
 
language
 barriers
 do
 interfere
 with
 communication.
 
 

 

 

 

 

 

 

 

 

 

 
68
 

 
Appendix
 C:
 Interview
 with
 Ms.
 Lillie
 

 
1. There
 are
 many
 other
 countries
 in
 need
 of
 help
 from
 the
 rest
 of
 the
 world.
 
 Why
 
were
 you
 drawn
 to
 Nepal?
 
Originally
 I’m
 not
 even
 quite
 sure
 what
 drew
 me
 to
 Nepal-­‐
 I
 guess
 to
 an
 
extent
 I
 can
 trace
 it
 back
 to
 my
 freshmen
 year
 in
 high
 school.
 In
 a
 social
 
sciences
 class
 we
 watched
 a
 documentary
 on
 the
 country
 Bhutan
 and
 I
 
became
 very
 interested
 in
 the
 culture
 and
 lifestyle
 there.
 Being
 a
 political
 
science
 major
 in
 college,
 I
 always
 chose
 Bhutan
 to
 do
 research
 on.
 Therefore
 
after
 graduating
 college
 while
 looking
 for
 an
 internship
 abroad,
 I
 ended
 up
 
choosing
 to
 go
 to
 Nepal-­‐
 thinking
 that
 it
 was
 probably
 somewhat
 similar
 of
 a
 
culture
 to
 Bhutan.
 I
 first
 went
 through
 a
 volunteer
 organization
 called
 World
 
Endeavors,
 and
 I’ve
 continued
 to
 go
 back
 on
 my
 own
 (but
 to
 the
 same
 school)
 
for
 the
 past
 couple
 years.
 
2. When
 did
 you
 begin
 your
 efforts
 with
 Nepal?
 
I
 first
 went
 to
 Nepal
 in
 June
 of
 2009,
 and
 I
 began
 my
 small
 school
 
sponsorship
 program
 that
 following
 fall/winter.
 
 
3. In
 your
 opinion,
 what
 is
 the
 one
 thing
 that
 the
 country
 needs
 most?
 
 For
 example,
 
education,
 economic
 stability,
 improved
 health
 care,
 etc.?
 
This
 is
 a
 somewhat
 difficult
 question
 to
 answer
 because
 I
 think
 both
 
education
 and
 improved
 health
 care
 are
 needed
 so
 much,
 but
 in
 slightly
 
different
 ways.
 Education,
 I
 believe
 is
 the
 most
 efficient
 way
 to
 attempt
 to
 

 

 
69
 

 
break
 the
 cycle
 of
 poverty
 in
 so
 many
 communities
 and
 countries.
 I
 think
 
education
 is
 the
 best
 possible
 long-­‐term
 investment
 one
 could
 make.
 With
 
better
 (and
 more)
 education
 comes
 a
 better
 government,
 better
 health
 care,
 
fewer
 children
 and
 older
 marrying
 ages.
 So
 I
 guess
 I
 would
 say
 I
 think
 
education
 is
 the
 thing
 that
 is
 needed
 the
 most
 for
 a
 long-­‐term
 solution
 
because
 in
 my
 opinion
 education
 has
 the
 means
 to
 help
 a
 society
 be
 able
 to
 
fix
 all
 their
 own
 problems
 for
 the
 most
 part.
 The
 problem
 is
 that
 this
 takes
 
lots
 of
 time
 to
 see
 results,
 so
 when
 the
 health
 care
 system
 is
 already
 so
 weak,
 
I
 think
 it’s
 impossible
 to
 stand
 by
 and
 wait
 for
 the
 people
 to
 all
 become
 more
 
educated
 to
 understand
 these
 health
 issues.
 Every
 time
 I
 have
 been
 to
 a
 
hospital
 or
 health
 clinic
 in
 Nepal
 it’s
 always
 a
 bit
 of
 a
 shock
 and
 it
 always
 
makes
 me
 feel
 like
 something
 has
 to
 be
 done
 to
 help
 change
 the
 health
 care
 
system.
 It
 seems
 to
 me
 that
 when
 Nepali
 people
 go
 to
 the
 hospital
 for
 almost
 
any
 reason,
 all
 too
 often
 the
 doctors
 always
 run
 urine
 and
 blood
 tests,
 take
 an
 
x-­‐ray
 and
 hardly
 ever
 seem
 to
 find
 the
 problem.
 So
 they
 give
 them
 a
 
prescription
 for
 something,
 usually
 pain
 killer
 if
 they
 don’t
 actually
 know
 
what’s
 wrong,
 and
 that’s
 that.
 I’m
 not
 in
 the
 health
 field,
 but
 to
 me
 there
 
seems
 something
 too
 wrong
 about
 that.
 I’m
 not
 sure
 if
 it’s
 the
 lack
 of
 training
 
or
 lack
 of
 equipment
 or
 a
 combination,
 but
 I
 feel
 like
 something
 has
 to
 
change.
 After
 I
 came
 home
 from
 my
 first
 trip
 to
 Nepal,
 I
 read
 somewhere
 that
 
Nepal
 has
 the
 third
 highest
 infant
 mortality
 rate
 in
 the
 world-­‐
 I’m
 not
 sure
 if
 
it
 is
 true
 or
 not,
 but
 it
 really
 surprised
 me
 and
 made
 me
 more
 aware
 of
 

 

 
70
 

 
baby
 and
 infant
 deaths
 when
 I
 have
 visited
 again.
 I
 came
 to
 find
 out
 the
 
amount
 of
 miscarriages
 is
 unbelievable,
 with
 most
 never
 officially
 reported.
 
Then
 I
 began
 to
 hear
 so
 many
 stories
 of
 babies
 dying
 right
 after
 they
 were
 
born,
 or
 a
 few
 months
 after
 birth.
 Then
 I
 also
 began
 to
 hear
 about
 infants
 
dying
 in
 accidents
 or
 getting
 sick.
 I
 couldn’t
 believe
 the
 amount
 of
 stories
 all
 
my
 friends
 in
 Nepal
 had
 told
 me,
 and
 I
 started
 thinking
 that
 statistic
 might
 
not
 be
 as
 far
 off
 as
 I
 originally
 thought.
 I
 think
 the
 people
 don’t
 have
 time
 to
 
wait
 for
 generations
 to
 become
 more
 education
 for
 improved
 health
 care-­‐
 the
 
amount
 of
 people
 suffering
 because
 of
 it
 is
 too
 great
 not
 to
 do
 anything.
 
 
4. Have
 you
 been
 met
 with
 resistance
 from
 the
 Nepali
 government?
 

 
No,
 no
 resistance
 I’ve
 experienced.
 
 
5. Is
 the
 government
 supportive
 of
 outside
 efforts?
 
I
 think
 for
 the
 most
 part
 the
 government
 appreciates
 the
 effort
 of
 outside
 
organizations
 coming
 to
 help
 the
 Nepali
 people.
 
 
6. How
 has
 Nepal
 changed
 you?
 
Personally,
 spending
 time
 in
 Nepal
 has
 changed
 my
 life
 in
 a
 few
 ways
 of
 
course.
 For
 one,
 I
 never
 thought
 I
 would
 be
 a
 teacher
 or
 enjoy
 teaching,
 but
 
I’ve
 grown
 very
 attached
 to
 the
 students
 of
 the
 school
 where
 I
 volunteer.
 I
 
think
 spending
 a
 significant
 amount
 of
 time
 in
 a
 developing
 country
 also
 
makes
 you
 appreciate
 certain
 things
 in
 the
 States,
 one
 being
 quality
 health
 
care.
 It’s
 expensive,
 but
 it’s
 quality,
 reliable
 and
 sanitary.
 As
 for
 my
 personal
 

 

 
71
 

 
life,
 I’m
 currently
 engaged
 to
 a
 Nepali
 man,
 a
 teacher
 at
 the
 school
 where
 I
 
teach-­‐
 so
 that
 has
 definitely
 changed
 my
 life
 for
 the
 better!
 
7. How
 has
 Nepal
 changed
 your
 outlook
 on
 health
 care
 around
 the
 world?
 
It
 just
 makes
 you
 think
 about
 things
 you
 never
 would
 have
 before.
 No
 one
 
should
 have
 to
 be
 carried
 hours
 and
 hours
 by
 stretcher
 to
 finally
 reach
 a
 
“hospital.”
 Or
 no
 boy
 should
 have
 to
 skip
 school
 due
 to
 illness,
 only
 to
 walk
 
by
 himself
 an
 hour
 to
 the
 “hospital”
 to
 get
 medicine,
 and
 walk
 an
 hour
 back
 
home.
 It
 makes
 you
 grateful
 to
 have
 so
 many
 doctors
 and
 hospitals
 here,
 
where
 you
 know
 they
 will
 work
 to
 find
 out
 your
 problem
 and
 make
 you
 
healthy.
 Seems
 like
 such
 a
 basic
 concept,
 but
 not
 everyone
 has
 that
 available
 
to
 them.
 
 
8. Do
 you
 think
 it
 is
 important
 to
 send
 US
 doctors
 and
 nurses
 to
 Nepal?
 
I
 definitely
 think
 it
 is
 very
 important
 to
 send
 US
 doctors
 and
 nurses
 to
 Nepal-­‐
 
but
 mostly
 for
 training.
 I
 think
 all
 doctors
 in
 every
 country
 want
 to
 be
 the
 
best
 at
 their
 job
 and
 help
 as
 many
 people
 as
 possible,
 so
 I
 think
 training
 to
 
help
 make
 the
 current
 doctors
 and
 nurses
 better,
 as
 well
 as
 helping
 to
 train
 
future
 doctors
 who
 are
 still
 in
 schooling.
 Nepali
 people
 in
 general
 I
 think
 
really
 appreciate
 people
 who
 are
 trying
 to
 help
 improve
 the
 lives
 of
 the
 
Nepalese
 people.
 
 
9. How
 has
 the
 social
 structure
 in
 Nepal
 affected
 the
 health
 care
 system?
 
While
 there
 is
 a
 caste
 system
 in
 Nepal,
 I
 think
 that
 is
 still
 most
 prevalent
 in
 
older
 generations
 and
 in
 more
 rural
 areas.
 Of
 what
 I’ve
 seen
 and
 heard,
 if
 a
 

 

 
72
 

 
person
 of
 the
 “untouchable”
 caste
 goes
 to
 a
 hospital
 for
 treatment,
 I
 believe
 
they
 get
 the
 same
 treatment
 as
 any
 other
 person.
 I
 think
 the
 caste
 system
 
currently
 is
 most
 restricting
 when
 it
 comes
 to
 religious
 events
 and
 eating
 
practices-­‐
 some
 people
 still
 refuse
 to
 eat
 rice
 or
 drink
 water
 that
 has
 been
 
touched
 by
 “untouchables.”
 
 
10. Have
 you
 seen
 improvements
 over
 the
 last
 several
 years?
 
Since
 I
 first
 went
 in
 2009,
 I’m
 not
 sure
 I’ve
 really
 noticed
 any
 changes
 in
 the
 
health
 care
 during
 that
 time.
 Nearby
 the
 village
 a
 new
 “hospital”-­‐
 in
 my
 
opinion
 it’s
 a
 health
 clinic,
 opened
 up
 so
 it
 is
 a
 little
 bit
 less
 of
 a
 walk
 if
 
someone
 needs
 immediate
 medical
 attention.
 However
 from
 the
 school
 it
 is
 
still
 about
 an
 hour
 walk
 away,
 and
 for
 some
 other
 villages
 nearby
 it’s
 still
 
hours
 of
 a
 walk
 away.
 
 
11. Do
 you
 think
 that
 the
 Nepali
 people
 are
 open
 to
 Western
 medicine
 and
 traditions?
 
This
 is
 an
 interesting
 question.
 I
 think
 the
 people
 want
 their
 children
 and
 
themselves
 to
 be
 healthy,
 so
 they
 are
 definitely
 open
 to
 western
 medicine.
 
However,
 many
 people
 in
 Nepal
 still
 believe
 in
 “witches”
 overtaking
 people’s
 
bodies
 and
 “making”
 them
 sick.
 In
 that
 case,
 many
 people
 visit
 “witch
 
doctors”
 when
 they
 are
 sick.
 Even
 friends
 I
 know
 who
 are
 educated
 and
 from
 
the
 city,
 they
 will
 say
 they
 don’t
 believe
 any
 of
 that,
 but
 I’ll
 later
 hear
 they
 
went
 to
 the
 doctor
 for
 a
 problem-­‐
 the
 doctor
 couldn’t
 fix
 it,
 so
 then
 they
 go
 to
 
a
 “witch
 doctor!”
 So
 while
 reason
 is
 sometimes
 against
 it,
 it’s
 still
 rooted
 
somewhere
 in
 people’s
 minds
 that
 it
 really
 might
 be
 an
 evil
 spirit
 and
 

 

 
73
 

 
something
 that
 a
 “witch
 doctor”
 can
 fix.
 Beliefs
 like
 this
 really
 take
 time
 to
 
change
 of
 course.
 However
 I
 think
 that
 if
 better
 health
 care
 was
 available,
 and
 
doctors
 were
 helping
 more
 with
 the
 problems,
 more
 people
 would
 go
 there
 
first
 for
 problems.
 I
 think
 that
 a
 huge
 reason
 for
 this
 is
 that
 when
 someone
 is
 
sick
 it
 seems
 so
 rare
 that
 the
 doctor
 
 explains
 exactly
 what
 is
 going
 on
 with
 
the
 body
 and
 why
 it
 is
 in
 pain
 or
 reacting
 that
 way.
 For
 example,
 while
 I
 was
 
in
 Nepal
 in
 2010,
 a
 boy
 of
 about
 10
 years
 old
 hadn’t
 been
 eating
 or
 drinking
 
for
 two
 or
 three
 days.
 He
 would
 say
 he
 was
 thirsty
 but
 then
 would
 get
 
extremely
 scared
 when
 someone
 tried
 to
 feed
 him
 water.
 The
 family
 didn’t
 
tell
 any
 one
 of
 his
 condition
 until
 it
 was
 getting
 too
 late,
 they
 had
 called
 a
 
“witch
 doctor”
 because
 they
 believed
 he
 was
 acting
 strange
 and
 thought
 an
 
evil
 spirit
 was
 inside
 him.
 When
 neighbors
 found
 out
 they
 tried
 to
 convince
 
them
 that
 the
 boy
 needed
 to
 be
 taken
 to
 the
 hospital
 immediately
 (even
 
though
 it
 was
 in
 the
 middle
 of
 the
 night).
 After
 a
 long
 time
 they
 were
 
attempting
 to
 take
 the
 boy
 to
 the
 hospital,
 however
 at
 this
 point
 the
 boy’s
 
mind
 was
 going
 (I’m
 assuming
 he
 was
 so
 dehydrated
 it
 was
 affecting
 his
 
brain?
 I’m
 no
 doctor,
 just
 a
 guess)
 and
 he
 started
 saying
 and
 doing
 very
 
strange
 things.
 This
 only
 re-­‐enforced
 their
 thoughts
 that
 an
 evil
 spirit
 was
 
inside
 him.
 In
 the
 end,
 they
 never
 made
 it
 to
 the
 hospital
 and
 the
 boy
 died.
 
The
 thing
 was,
 the
 family
 never
 got
 an
 answer
 as
 to
 what
 was
 wrong
 with
 the
 
boy
 medically,
 so
 I
 really
 don’t
 think
 it
 changed
 their
 thinking
 about
 
“witches”
 and
 “witch
 doctors.”
 However,
 even
 if
 people
 see
 “witch
 doctors”
 

 

 
74
 

 
most
 of
 them
 are
 always
 also
 willing
 to
 visit
 a
 hospital,
 because
 of
 course
 any
 
way
 they
 want
 the
 sick
 person
 to
 be
 healthy.
 I
 believe
 if
 medical
 conditions
 
are
 explained
 more
 thoroughly
 people
 will
 begin
 to
 understand
 why
 the
 body
 
is
 reacting
 that
 way,
 and
 less
 likely
 to
 jump
 to
 the
 conclusion
 of
 an
 evil
 spirit.
 
 
12. Is
 the
 language
 barrier
 difficult?
 
 

 
I
 don’t
 think
 the
 language
 barrier
 is
 very
 difficult,
 you
 can
 almost
 always
 find
 
someone
 who
 can
 speak
 enough
 English
 to
 translate
 for
 someone
 else
 if
 need
 
be.
 Even
 in
 the
 villages
 now,
 many
 kids
 are
 learning
 English,
 and
 learning
 it
 
fast.
 
 
13. Is
 there
 a
 major
 gap
 in
 the
 understanding
 of
 common
 Western
 practices,
 such
 as
 
hand
 washing?
 
I
 didn’t
 have
 lots
 of
 experience
 with
 Nepali
 doctors
 and
 if
 they
 understand
 
those
 practices.
 I
 was
 visiting
 an
 emergency
 room
 in
 Pokhara
 (the
 second
 
largest
 city)
 and
 I
 was
 shocked
 there
 was
 dried
 blood
 on
 some
 of
 the
 
counters
 and
 floors.
 I
 also
 saw
 a
 man
 (doctor
 or
 nurse,
 I
 don’t
 know)
 touch
 a
 
man’s
 bloody
 wound
 with
 no
 gloves
 on,
 only
 to
 go
 to
 the
 next
 patient
 without
 
washing
 his
 hands!
 I
 was
 thinking
 if
 this
 was
 even
 a
 problem
 in
 large
 cities,
 I
 
can’t
 imagine
 the
 sanitation
 in
 village
 hospitals.
 I
 think
 they
 understand
 it
 to
 
an
 extent,
 but
 don’t
 realize
 the
 consequences
 enough
 to
 always
 change
 the
 
behavior.
 
 

 

 

 
75
 

 
14. How
 difficult
 do
 you
 expect
 it
 to
 be
 for
 the
 Nepalese
 to
 adopt
 Western
 medical
 and
 
sanitation
 principles?
 
I
 don’t
 think
 it
 would
 be
 that
 difficult,
 of
 course
 it
 always
 takes
 time
 to
 break
 
and
 changes
 practices.
 However
 I
 think
 if
 people
 understood
 the
 
consequences
 of
 how
 diseases
 spread
 due
 to
 lack
 of
 sanitation,
 they
 will
 
change
 their
 ways. 
Asset Metadata
Creator Perez-Silva, Gabriella (author) 
Core Title Infant and maternal health care in Nepal 
Contributor Electronically uploaded by the author (provenance) 
School Annenberg School for Communication 
Degree Master of Arts 
Degree Program Strategic Public Relations 
Publication Date 07/25/2012 
Defense Date 07/25/2012 
Publisher University of Southern California (original), University of Southern California. Libraries (digital) 
Tag health care,Infant,maternal,Nepal,OAI-PMH Harvest 
Language English
Advisor Floto, Jennifer D. (committee chair), Jackson, Laura Min (committee member), Wang, Jay (committee member) 
Creator Email gabyperezsilva@gmail.com 
Permanent Link (DOI) https://doi.org/10.25549/usctheses-c3-62853 
Unique identifier UC11290062 
Identifier usctheses-c3-62853 (legacy record id) 
Legacy Identifier etd-PerezSilva-981.pdf 
Dmrecord 62853 
Document Type Thesis 
Rights Perez-Silva, Gabriella 
Type texts
Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection) 
Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law.  Electronic access is being provided by the USC Libraries in agreement with the a... 
Repository Name University of Southern California Digital Library
Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA
Abstract (if available)
Abstract This paper examines the past and present future of Nepal, its culture and its health care.  Specifically, it addresses some of the primary issues surrounding infant and maternal health care in the rural villages in the foothills of the Himalayan Mountains.  The purpose of this analysis is to not only understand the main causes of death and the medical and cultural cures for the causes of death, but also to understand the reasons that these cures are not being employed.  Another aim is to study how communication and public relations can increase awareness of diseases and disease prevention in rural areas, and to explore the obstacles that language and cultural differences can create when introducing Western concepts into these areas.  The key issues addressed in this paper include the geographical origins of Nepal and how the topography has contributed to the cultural composition of the country, the main causes of infant and maternal deaths, and the possible solutions for preventable deaths.  The results prove that while most people in the United States are unfamiliar with the problems in Nepal, they are sympathetic to charitable causes in developing countries, and are will to donate to non-governmental organizations.  The principal conclusion is that despite the fact that many Nepalis practice ancient customs, the younger generations are open to Western ideas, and through proper communication, are likely to implement these new customs into their daily lives. 
Tags
maternal
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University of Southern California Dissertations and Theses 
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