E-Kantipur

Ambika Devi was just 12 years old when she got married. By 15, she had given birth to her eldest son and at 43 to her youngest daughter, Aana. All in all, she gave birth to 11 children, only six of whom survived. Ambika died two years ago from pulmonary fibrosis. Aana, also a close friend of mine, said she was an unwanted child and her mother originally sought to abort the pregnancy. This is a story of the 1970s, when abortion was illegal and subject to a jail sentence of up to 20 years.

According to Manusmriti, one of the ancient Hindu teachings on the law, consumption of any food touched or served by a woman who has had an abortion was considered a sin. The Muluki Ain, the Country Code, also had a separate legal provision on abortion under the article Jatakmareko (killing of the foetus). According to the Muluki Ain, both the woman and any person associated with performing an abortion would be jailed.

Traumatised by the dreadful taboo of the patriarchy, the potential ostracism and the frightening penalties, Ambika had no choice but to give birth. But even in the 1970s there were women who risked their health and social status by resorting to clandestine abortion. They would either seek abortion services in neighbouring Indian cities or choose dangerous traditional ways back home.

When family planning services were first introduced in Nepal more than 50 years ago, population control was encouraged by strongly pushing contraceptive means for women. Various research reports conducted on reproductive health and family planning in late 1970s and early 1980s suggest that despite the introduction of pills like Nilocon Chakki and Sunaulo Gulaf, Nepali women and their spouses preferred female sterilisation and injectable birth control methods over pills. That is why injectables like depo-provera gained so much popularity among Nepali women.    

Today, there is a huge statistical leap in terms of the Contraceptive Prevalence Rate (CPR) with the significant decline of the Total Fertility Rate (TFR). According to the Nepal Demographic and Health Survey report, the use of modern methods of contraception has dramatically increased in the last few years with the fertility rate dropping to an average of 3.1 births over a woman’s lifetime compared to 6.3 births during the 1970s.

Although the upward graph lines indicate the increasing trend of modern contraceptive use over the past few years, the discontinuation rate remains as high as it used to be 30 years ago. Even today, more than half of the women contraceptive users discontinue their use within a year of starting, and there exists a huge regional disparity. For example, only one-quarter of married women in the Far Western hills use modern methods of contraception, whereas the usage rate for women of the Far Western Tarai is 65 percent.  

Women in rural areas are still bound to risk their lives, primarily because of a lack of say over their sexual and reproductive security: their early marriages, their reproductive health choices and the number, timing and spacing of their children, to name a few. This has a lot to do with their limited access to information related to sexual and reproductive health and family planning. Though the continued efforts towards reducing the fertility rate by the government, non-government and private sectors are appreciable, long-term commitment and a sustained coherent approach, especially towards reaching rural

youth of underserved areas, is a fundamental need.   

Nepal belongs to the group of countries with high rates of adolescent pregnancy. Roughly 20 percent of Nepali adolescent girls are either pregnant or become mothers to their first babies. About half of these adolescent girls do not receive adequate obstetric care and 19 percent of maternal deaths occur among this age group. Moreover, almost 80 percent of women still give birth at home under unsafe conditions and often times in the presence of unskilled birth attendants. Data indicate that the average percentage of the presence of skilled attendants at births is just 19.   One can easily imagine how important interventions to increase the awareness and demand for sexual and reproductive health services are. Reproductive health experts suggest that it is crucial to combine the supply side interventions with demand side activities to create a more enabling environment for adolescent girls to seek and obtain sexual health services. The government needs to work in partnership with civil society and grassroots organisations to reach the youth population effectively.

As I was drafting this piece, Aana, sitting close to me, made a reference to the case of Nandu Devi Dadal in Bajura district, which she had read the other day. Nandu, 40, who was living with a dead foetus, succumbed to death while waiting to reach an equipped health-care facility for treatment. We agreed that it is time to divert resources to better equipping local health posts, particularly in remote VDCs such as Kolti in Bajura. Locals should be able to avail safe reproductive health treatment at a reasonable proximity. Nandu, unfortunately, wasn’t. 

While the Ministry of Health and Family Planning’s on-going efforts to draft a strategic human resource (HR) plan and country HR profile to facilitate enhanced public access to healthcare by June 2011 is laudable, such efforts have to be complemented by comparable investments in tangible services.

upadhyay_b@yahoo.com

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