Socio-cultural and Health Care Contexts of Perinatal Survival in Rural Mountain Villages of Nepal

Author: Mohan Paudel

Paudel, Mohan, 2018 Socio-cultural and Health Care Contexts of Perinatal Survival in Rural Mountain Villages of Nepal, Flinders University, College of Medicine and Public Health

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Worldwide, over 14,500 perinatal deaths occur daily, with a majority happening in Sub Saharan Africa and South Asia. Nepal has high perinatal mortality with its mountainous areas showing the highest rates. Nationally, only about half of the women utilise skilled care during pregnancy, childbirth and postnatal periods, and fewer still in the mountainous areas. The focus of research and policy to improve perinatal survival has so far remained on their medical determinants. The present study aims to examine socio-cultural factors influencing perinatal survival in two remote Nepalese mountain villages. The specific objectives of the thesis are to: 1) explore women’s and their family members’ experience and beliefs about perinatal sickness and deaths; 2) examine the socio-cultural context of experiencing pregnancy, childbirth and perinatal deaths; 3) examine the health care delivery contexts of perinatal survival at primary health care levels; and 4) consider the implications for health policy development and implementation in the villages.

This is a qualitative study, informed by social constructionist and critical theoretical perspectives and based on in-depth interviews of women and family members experiencing perinatal deaths in the selected villages. Interview data were supplemented by reviews of policy documents and interviews of frontline health workers and others. Data were analysed using inductive thematic analysis with comprehensive coding processes. Three key themes and sub-themes emerged from the data:

1. Fatalistic beliefs concerning acceptance of perinatal sickness and deaths. Sub-themes: i) ‘everyone has gone through it’: perinatal death as a natural occurrence; ii) The will of Dewata (God) as a factor in health and sickness: a cause of, and means to overcome sickness in mother and baby; iii) Karma (past deeds), Bhagya (fate) or Lekhanta (destiny) - ways of rationalising perinatal deaths.

2. Gendered social constructs of motherhood and poor perinatal survival. Sub-themes: i) gendered social construct and vulnerability to poor perinatal survival: child marriages, son preference and repeated childbearing; ii) pregnancy and childbirth in intra-familial dynamics of relationships and power; iii) perception of childbirth as a polluted event: birth in Gotha (cowshed), giving birth alone.

3. Declining essence of primary health care and health governance failures. Sub-themes: i) Approach of health care delivery: low focus on empowerment and engagement; ii) quality of health care: poor acceptance, feeling unsafe and uncomfortable in health facilities; iii) health governance failures in delivering pregnancy and childbirth services.

The findings reveal the insufficiency of medically oriented health services for reducing this region’s continuing high perinatal mortality. Addressing the social and cultural determinants of perinatal mortality is paramount for its prevention. This study makes a case for perinatal survival drawing on lay perspectives gained from the women and their families, allowing effective exploration of factors influencing perinatal survival within their socio-cultural and health service contexts. It shows how to consider socio-cultural factors including gender, power structure and social norms for developing appropriate policies and programs for improving perinatal survival. It calls for urgent attention to develop policies and services culturally and socially appropriate to enable women access to safer perinatal outcomes.

Keywords: Perinatal, neonatal, infant, health care, childbirth, mortality, survival, gender, religio-cultural, health system, Nepal, social determinant, culture, mountain

Subject: Medicine thesis, Public Health thesis

Thesis type: Doctor of Philosophy
Completed: 2018
School: College of Medicine and Public Health
Supervisor: Sara Javanparast