By ALLYN GAESTEL & ALLISON SHELLEY:
In the slanted golden light of late afternoon, Lalu Nepali beat rice with a long wooden mallet. The wood extended a foot above her head, and she dropped it onto her pile of grains, separating rice from the hulls with a rhythmic thud, thud, thud. A white scarf was wrapped tightly around her midsection as if to hold in her nearly bursting belly. She grunted at the exertion with each strike. Thud, grunt, thud, grunt. Nine months pregnant, she was due any day.
Nepal is viewed as one of the success stories in the global effort to improve women’s chances in pregnancy and delivery. The United Nations created the Millennium Development Goals to measure improvements in various aspects of life in developing countries, and the fifth goal is to reduce by 75 percent the rate of women dying around pregnancy and delivery by 2015. Almost nowhere has this been accomplished, as changing birth outcomes has proven more challenging than anticipated.
Nepal is one of just a few countries that has already significantly reduced maternal deaths, and is on track to achieve MDG 5. But investments in the health system are crippled by engrained gender disparity. Until the status of women improves, childbirth will remain a dangerous labor.
The Nepali government has worked hard to improve their maternal health statistics, and arranged national policy around the international development agenda. There is a rigorous family planning program which has helped lower the average number of children women have from 4.6 in 1996 to 2.6 in 2011. Government spending on health tripled between 2006 and 2011. Abortion was legalized and reproductive rights were specifically included in the interim constitution of 2007, and more women are birthing in health centers, motivated in part by a government program that pays women to birth in clinics.
Lalu lives deep in Far-Western Nepal, a two-day’s drive and a world away from the bustling capitol where health policy is hammered out. Her village is stacked in tiers on the edge of a mountain, jutting over a deep valley. Across Achham, the endless hills are carved into terraces of fields planted with potato and wheat seedlings.
To get to her local clinic Lalu had to walk one to two hours, depending on her pain, along a path cut out of the side of the mountain, slowly ascending to the main dirt road. Then she had to double back on the opposite face of the mountain, descending a slippery, pebble strewn path. The health post is off the main road, past a tiny town comprised of teashops selling little more than hard candies and instant noodles. A steep, rocky path leads down to the clinic; it feels like a landslide waiting to happen.
But Lalu made the trek several times throughout her pregnancy to take advantage of prenatal checkups, and the 100 Nepali Rupees ($1.03 USD) she earned for each visit. A central part of Nepal’s efforts to make labor safer has been to entice women to birth in clinics and hospitals. At Lalu’s local clinic, a fresh-faced midwife named Parvati Kayat has received laboring women desperately trying to reach the health clinic to get the seemingly nominal stipend. “Some women are so poor that even if they deliver on the way they struggle to get here just to get the 1,000 Rupees ($10.57),” she said. The program pays between 500 and 1,500 Nepali Rupees, or $5 to $15 USD, depending on the region.
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