Safe Motherhood
Reducing Maternal Mortality

By Jhabindra Bhandari

IN a country like Nepal where primary health care services are limited in the rural areas, the status of reproductive health presents a gloomy picture. Lack of awareness on health and education including poor health care services are the major issues of public health. High infant and maternal mortality, rapid population growth , poor nutritional status, poor sanitation and lack of awareness on health issues are causing negative impacts on public health.

Grim Reality

Nepal has one of the highest maternal mortality rates in the world. The maternal mortality rate is 539 per 100,000 live births and hence this pinpoints the grim reality of maternal health in the country. Majority of women do not have access to maternal health care services due to a number of social, economic and cultural factors. Therefore, a multi-sectoral approach is needed to include both health and non health interventions that promote access to health services.

Safe motherhood is one of the priority programmes of Ministry of Health. According to the annual report of Department of Health Services - 2000/2001, the target of safe motherhood programme is to contribute to the reduction of maternal mortality rate from the rate of 539 per 100,000 live births to 400 per 100,000 live births by the end of the Ninth Five Year Plan period and 250 by 2017. Similarly, the other important target is to contribute to the reduction of infant mortality rate from 78 per 1,000 to 34.4 by 2017.

According to the report of WHO - South East Asia Region 2001, more than 60 per cent of maternal deaths occur after birth, more than half of these take place within one day of delivery globally. Some 80 per cent of all maternal deaths occur due to direct obstetric complications. Thus maternal death is a tragic outcome of continuing societal neglect of women's health, their unequal access to life-saving emergency obstetric care, and their lack of decision making power.

Over the last two decades, countries of South East Asia region have made concerted efforts to promote safe motherhood since the global launching of the safe motherhood initiative in 1987. The region that is home to nearly half of the world's poor and women, are affected by poverty. The region accounts for 40 per cent of global maternal deaths.

The declaration on health and development in the South East Asia Region in the 21st century has identified reduction of maternal mortality as one of the foremost challenges advocated for public health actions. Despite these efforts, maternal and new born deaths have remained high in the region. Thousands of women continue to die in child birth which is the leading cause of death among women of reproductive age in the region.

The three delays are quite particular which may lead to death of a pregnant woman and a new born baby. Firstly, the delay is related to lack of knowledge about the dangerous signs and need for skill attendant at delivery. It means there is delay in decision making in case of the complications. Secondly, there is a delay in reaching the health facilities due to lack of community awareness and poor use of available community resources. And thirdly, there is a delay in receiving proper treatment due to poor management and quality of existing health services.

The role of families and communities is to encourage, empower and facilitate women to seek health care and family planning services. Massive awareness against dangerous signs and complications during pregnancy and delivery is most vital for timely referral and care. This means that social mobilisation is one of the strategies to overcome the three delays in seeking and receiving care. Local NGOs can contribute by supplementing and complementing the government's efforts of achieving safe motherhood to reduce maternal and neonatal mortality significantly.

Pragmatic strategies to reach the goal of safe motherhood are required. Efforts are urgent to take place in order to strengthen and expand basic maternal care services including family planning. On the other side, there is growing need to establish functional referral and transport systems from communities to district hospitals for obstetric emergencies and high-risk pregnancies. At the village level, it is high time to strengthen community-based maternity care services through Female Community Health Volunteers, Maternal Child Health and Workers and Traditional Birth Attendants.

Important

In order to promote inter-sectoral collaboration for safe motherhood, advocacy for reproductive health, including safe motherhood at all levels and capacity building of service providers are extremely important. Similarly, participatory operational research on safe motherhood contributes significantly to improve planning for quality services and more cost -effective interventions. Information, Education and Communication activities need to be expanded effectively in the communities to improve health seeking behaviour. More importantly, mainstreaming safe motherhood issues in local development plans and programmes is crucial to reduce maternal mortality - thereby raising the status of women in society.

Problems Of Women Entrepreneurs

By Santanu Regmi

ACCORDING to 1991 population census, women constituted about 51 per cent of the total population of Nepal. As majority of the population lives in rural areas and the economy is primarily agrarian, women carry out most of the burden of family and farm work. Overwhelming majority of rural women is trapped in the fumes of poverty as they have very little access to education, training, resources and remunerative employment opportunity.

Discrimination

Based on Human Development Report 2000, women tend to live longer in all countries of the world except in Nepal and Maldives. For example, life expectancy of women in Nepal is 57.6 (country's average 57.8) years as compared to men's 58.7 years, which is exceptional case next to Maldives among 174 countries included in the report. Similarly, adult literacy rate of women is 21.7 (country average 39.2) per cent against 56.9 per cent for their male counterparts. Gross enrollment ratio in school is 69 per cent for male whereas it is only 49 per cent for them. Furthermore, women's share in Gross Domestic Product (GDP) per capita is almost half (US$ 789) their male counterparts (US$ 1521). This is mainly because women do not get social and economic repute right from the birth to their death. There exists huge discrimination is sharing food, health care, and education opportunity among men and women but women are loaded with works, which they have to carry on throughout their lifetime.

In poor rural societies, women are made to live on residual food supply. Their male counterparts dominate in most of the remunerative work place consequently leading to their weak economic status. Rural women are mostly engaged in agriculture and other domestic chores but economic value of their work is hardly counted making them economically inactive. Men as a controller of resources in the society tend to dictate possible economic opportunities and hardly allow their female counterparts to make any economic decision. In a male dominated patriarchal society, men snatch most of the opportunities leaving women only with unwanted and difficult but less moneymaking jobs. Even with small number of women who have opportunity of higher education, social mobility and awareness, remain confined in their traditionally prescribed roles.

Nepalese society still entertains the strong traditional values in favour of males and greater mobility on the part of women is not socially accepted. Women entrepreneurs face several problems of resources scarcity, low risk taking capacity, loss of proprietorship in informal sector and limited market access. Women are economically inactive as they lack the productive assets- land and property and credit facilities. Both the formal and non-formal credit institutions tend to fund potential entrepreneurs who can offer tangible collateral for the loan. But women do not possess such ancestral or other assets to make use for credit purpose.

The informal financing facilities like village moneylenders or so-called landlords are also more interested in earning higher interest or grabbing debtor's property rather than facilitating poor people in need. Hence, access to credit is one of the major stumbling blocks for women entrepreneurs particularly rural women engaged in agriculture sector.

Despite government and non-government organisations efforts to respond to the social discrimination against women, they are still far behind in gaining equal position to men. This could perhaps be attributed more to the inadequate and half hearted implementation of government's gender related policy. The social milieu still prefers women to confine their roles within the household. As a result, women are provided minimum opportunity to work outside their homes. Even if they get employment, normally they are able to get lower position in hierarchy mainly due to deprivation of education and skill development opportunities. Women when employed in the public or private sector hardly get career development opportunities due to their social responsibilities and employer's biases.
However, women, with their own effort and efforts of various government and non-government organisations geared to tackle the gender issue, are slowly and gradually breaking the social trap and enabling themselves to confront existing challenges. Many development-oriented organisations emerged with their lucrative programmes to empower women and make them able to generate their income to boost their economic condition.

It has been experienced that an increasing number of women are entering into work force in formal and informal employment sectors. Majority of women work in formal sectors as semi-skilled and skilled labours while in informal sectors they have shown their high degree of involvement as self-employed workers. But there is an obvious fact that self-employed women are encountering difficulties like inadequacy of capital fund, access to institutional credit, lack of market accessibility and so on.

Bright Future

Women entrepreneurs who are engaged in home based industries like handicraft, food processing, garments, hosieries, sewing and knitting, carpet weaving etc., are also unable to generate sufficient income for their subsistence since these industries are gradually dying as a result of penetration of cheaper foreign goods in the market. If the government strongly implements strategies and policies designed to cope with gender discrimination, then women will find an open avenue to develop their aptitudes which subsequently would support to meet their aspirations and expectations. The increasing trend of women taking keen interest in their career development and enterprise activities rather than restricting themselves only within the household chores has somehow depicted their future in Nepal.