Infant and maternal health care in Nepal

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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

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avoid

infection
during
home.”
PATH.
http://www.path.org/projects/clean-‐
delivery_kit.php

Sinha,
Kounteya.
“WHO
lauds
Indian
scheme
to
reduce
neonatal
mortality.”
Times
of

India.
February
2012.
http://timesofindia.indiatimes.com/india/WHO-‐lauds-‐
Indian-‐scheme-‐to-‐reduce-‐neonatal-‐
mortality/articleshow/11904619.cms?intenttarget=no#.Tz8pwX_T6iw.email

Sinha,
Kounteya.
“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

Dr.
Sohl,
Bertram,
M.D.
and
Dr.
Hadi
Emamian,
M.D.
Personal
interview.

California,

March
2012.

“Study
quantifies
impact
of
unsafe
water
and
poor
sanitation
on
child
and
maternal

mortality.”
News
Release,
United
Nations
University.
14
February
2012.

64

Suvedi,
Bal
Krishna,
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.
Web.

“Tibet’s
Stateless
Nationals:
Tibetan
Refugees
in
Nepal.”

Tibet
Justice
Center.

http://www.tibetjustice.org/reports/nepal.pdf.

“Travel
Guide:
The
Terai.”
Nepal
Home
Page.

http://www.nepalhomepage.com/travel/places/terai/terai.html

Whelpton,
John.
A
History
of
Nepal.
Cambridge:
Cambridge
University
Press,
2005.

“The
World
Factbook,
Infant
Mortality
Rate.”
Central
Intelligence
Agency.
May
2012.

https://www.cia.gov/library/publications/the-‐world-‐
factbook/rankorder/2091rank.html

“World
Health
Statistics.”
World
Health
Organization.
Figure
1:
Mortality
rate
in

children
under
5
by
WHO
region.
Page
13.

http://www.who.int/whosis/whostat/EN_WHS10_Full.pdf.
2010.

“World
Population
Prospects:
The
2010
Revision.”
United
Nations,
Department
of

Economic
and
Social
Affairs,
Population
Division
(2011),
CD-‐ROM
Edition.

“World
Population
Prospects.”
United
Nations
Department
of
Economic
and
Social

Affairs.
28
June
2011.
http://esa.un.org/unpd/wpp/Excel-‐Data/mortality.htm

Yadav,
Sohan
Ran.
Nepal:
Feudalism
and
Rural
Formation.
New
Delhi,
Cosmo

Publications,
1984.

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.

Abstract (if available)

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