A decade of qualitative research

informs equity and access programming

for safer motherhood in Nepal

Mary Manandhar, Bindu Gautam, Hom Nath Subedi,

Sumi Devkota, Hazel Simpson, Deborah Thomas,
Greg Whiteside, Ben Rolfe, Laxmi Raj Pathak and BK Subedi
“The link between social disadvantage and mortality is
subtle and indirect but maternal and newborn survival and
good health are ultimately the result of a society that
values women and children irrespective of their race,
social, economic, and political status and provides
unimpeded access to information and health services from
the household to the hospital.”

Rosato, M. The Lancet Vol 372 September 13, 2008

 International context

• Growing attention to social conditions

as part of strengthening more
equitable and rights-based health
systems

• Nepal can offer lessons and preliminary

evidence of the impact of action on the
social determinants of maternal health

Commission on the Social Determinants of Health WHO 2008

 Safer motherhood programming in Nepal
Between 1996 and 2006, Nepal halved its MMR to 281
Nepal Safe Motherhood Project (NSMP) 1996–2004
Support to Safe Motherhood Programme (SSMP) 2005-10, with an
Equity and Access programme (EAP)

2 GoN health systems strengthening

programmes focused on:
• increasing attention to social determinants
and inclusion
• emergence and intensification of
a rights-based approach
 Qualitative research
• Articulates women's voices - part of RBA
• Provides a lexicon of local maternal and neonatal health
terms for Behaviour Change Interventions
• Details contextual barriers to access to health care for
different social groups (ethnicity / caste / gender / region)
• Informs efforts to improve equity and access for socially
excluded groups
• Strengthens accountability and demand
 Contextual barriers
• Beliefs about the spiritual causes
of sickness and crisis determine
care-seeking in favour of
traditional healers
• Fatalistic beliefs dull urgency

• Complex pattern of delays and

detours, and recourse to a variety
of care providers (often from
different health systems) in most
health crises “every kind of wind,
every kind of ghost”
 Contextual barriers
• Women exist in a complex web
of relationships

• Socio-cultural norms related to ritual blood pollution,

shame (laj) and avoiding loss of family prestige (ijjat) greatly
influence delay

• The woman in childbirth is not a key decision-maker and is

expected to defer to her in-laws, husband and healer
 NSMP qualitative research
Highlighted previously unexplored social determinants
of maternal health:

• Regional, caste, ethnic- based social exclusion which influence

quality of care at the provider-client interface

• Persisting strength of indigenous beliefs and practices about

sickness causation which influence care-seeking and the
plurality of the ‘health system’

• Persisting deep-rooted gender inequity operating at household

and community levels influencing access to available services
Ethnic / caste inequities in access to health care

Bennett, Dahal and Govindsamy 2008 (Further analysis of Nepal DHS 2006)
 Context is everything
• This is not principally a ‘lack of knowledge’ problem

• Need to understand the deeply hierarchical nature of Nepali

society and gendered cultural traditions

• ‘Sensitisation’ solves none of these problems

• Nor does simply describing the complexity

 Contested debate and novel solutions

• Challenge the ideology of male domination: question male-controlled customary laws,

affect on health

• Reflect on the family as the core of a woman’s own concept of self-hood

• Enable women to be heard and to gain control

• Support communities to seek and reflect on alternative behaviours and participate in

their own solutions

• Transform the institutions and structures

Bringing transformative change to scale

EAP’s Key Informant Monitoring (KIM)

Advocacy: local and national

Accountability: local, district, regional, national
Monitoring ethnicity in routine data collection
Community mobilisation approaches
Participatory Video
 Challenges and opportunities
• Research to understand barriers to access and inclusion
• Disaggregated data, including for maternal morality
• Address capacity to use these data in programming
• Forget ‘sensitization’
• The Nepal experience demonstrates the potential of:
– Scaling flexible participatory community mobilisation
– Integrated BCC informed by well supported research
– Intensive capacity building
– Long horizons for success
 Influencing at national level

• The safe motherhood policies, the national safe motherhood

programmes and the Interim Constitution have reflected the
historical shift to incorporate both public health and human
rights concerns (e.g. right to freedom from discrimination)

• New Gender and Social Inclusion Unit at the heart of

government to strengthen this trend