Bajura CARE study no photos

CARE - NEPAL
BIRTHING PRACTICES STUDY
Remote Area Basic Needs Project - Bajura

CARE NEPAL
DRAFT
BIRTHING PRACTICES STUDY
Remote Area Basic Needs Project - Bajura, Nepal
Dr Mary Manandhar, Consultant
May 1999
Kathmandu

Birthing practices study, Bajura - Draft Report
CONTENTS
page
Acknowledgements
Acronyms
List of photographs
1. Summary
2. Study background and rationale
3. Methodology
3.1 Choice of VDCs and general approach
3.2 Qualitative research techniques
4. Findings
4.1 Place of delivery, and rituals connected with the confinement period
4.2 Diet during delivery period
4.3 Feeding of colostrum
4.4 Attendance by a trained TBA at delivery
4.5 Use of SHDK
5. Case studies
5.1 Behind the stone border : a home delivery in Manakot
5.2 Bad luck and behaviour change : from house to chhau ghar in Jugada
5.3 A threshold case of home delivery from a DAG community in Pandusen
6. Study strengths and limitations
6.1 Strengths
6.2 Limitations
7. Lessons learned
7.1 Assumptions and definitions
7.2 Belief, knowledge and changing behaviour
7.3 Safe Motherhood as a gender issue
7.4 Supporting the TTBA programme
7.5 The potential of the SHDK
8. Recommendations
List of reports and publications
Appendices
I CARE Nepal Terms of Reference
II Study itinerary
III VDC maps
IV Semi-structured interview (SSI) questionnaire (English version)
V Focus groups (FG) guidelines (English version)
VI Glossary of local terms
VII List of people met

Acknowledgements
Most tribute should be paid to the many people of different ages in the three VDCs visited in
Bajura district who gave their time and shared their stories despite the busy agricultural season
and a multitude of day to day difficulties.
I am grateful for the assistance, company and enthusiasm of Mrs Bina Rana Khagi, a
Kathmandu-based CHO of CARE Nepal.
The success of this study is very largely due to the energy and commitment of Mrs Sunita
Shirish Thapa (Manakot and Jugada VDCs) and Miss Suja Rai (Pandusen VDC), both CARE
Community Health Extension professionals, whose skill in facilitating community goodwill
greatly helped the data collection process.
Thanks are also due to the Project Manager of the RABNP, Mr. Gopal Shrestha, and all sector
heads, especially Ms Indra Ghimire, and other field-based staff, who generously provided
information and opinions at various times.
The hospitality of all CARE Bajura staff during my visit is gratefully acknowledged, as is the
considerable logistical support from CARE staff in both Kathmandu and Nepalgunj, despite bad
weather and election disruptions.
In Kathmandu, I appreciate the guidance and help of Jake O’Sullivan, Marcy Vigoda, and
Puroshottam Acharya in completing my assignment.
Lastly, I thank the many people in Kathmandu and beyond who shared their ideas and
experiences on birthing practices in Nepal.

ACRONYMS
ANM
CDC
DAG
DHO
FCHV
FG
HP
LDO
LRSP
MCHW
MG
NFE
NON DAG
PHO
RABNP
RDO
SHDK
SSI
TBA
VDC
VHW

List of photographs
page
1. CARE study staff with members of the Community Development
Organisation in Manakot
2. Focus group dicussion with men in Manakot
3. Focus group with mothers in Jugada
4. SSIs with two dhami jhankris in Manakot
5. Focus group discussion with DAG grandmothers in Jugada
6. Grandmothers in Pandusen discussing picture of delivery in
animal shed ghot
7. Grandfathers in Pandusen investigating the SHDK (grouped are DAG,
separate lone man to the right is a DAG dhami)
8. Chhau ghar (open small door to the left of straw) at the side of the house
in Jugada
9. Chhau ghar in non-DAG house in Manakot
10. Chhau ghot (left open doorway on ground floor) and animal shed ghot
(right open doorway on ground floor) in Jugada
11. Chhau ghar on ground floor in Pandusen
12. Chhau ghar in non-DAG house in Jugada (left doorway on ground floor,
being used for wood storage)
13. Recent delivery in a chhau ghar in Jugada
14. Same mother showing location of chhau ghar on ground floor of house.
Fishing net above the doorway is for protection from bhot and bokshi
15. Recent delivery in an animal shed ghot in Pandusen
16. Case study from Manakot. Recent delivery in the house behind the
stone border.
17. Case study from Pandusen
18. Family and house of case from Pandusen. Animal shed ghot on
ground floor. Case delivered in the middle floor, doorway shown
19. Case study from Jugada

STUDY RATIONALE AND BACKGROUND
The full CARE Nepal Terms of Reference for the consultancy are given in Appendix 1,
along with a map showing the location of Bajura District in the mid-western region of
Nepal. What follows here is an overview of on Safe Motherhood by CARE Nepal and
others, a listing of the study objectives, and background to the main study themes.
Safe motherhood in Nepal
The global Safe Motherhood Initiative was launched at an international
conference in 1987. The main goal of the Initiative was to promote the right of
access to appropriate reproductive and other health care services that will
enable women to go safely through pregnancy and childbirth. Nepal adopted a
National Plan of Action in 1993 under its Safe Motherhood Programme within
the Department of Health Services, Family Health Division. The first phase of
the programme is currently underway in 10 districts of the country. The
National TBA Training program was set up in 1988 and works in close
collaboration with the Safe Motherhood Programme at all levels. An evaluation
has recently been conducted based on data from 7 districts (1998).
Nationwide to date, the foci of most programmes aimed at improving safe
motherhood practices in Nepal have been IEC activities (CEDPA, Safe
Motherhood Network), the promotion and supply of “Sutkeri Samagri”, the
Safe Home Delivery Kit (SHDK), and the training of service providers such as
TBAs and FCHVs using the HMG/ Redd Barna curricula. There are several
other approaches too such as improving the capacity of emergency obstetric
services (DfID-funded Nepal Safer Motherhood Project) and the establishment
of a low-cost birthing centre (RUWDUC).
Safe motherhood in Bajura
The remote far western and mid-western hill districts of Nepal have received
the least attention in terms of safe motherhood programmes compared to
other parts of the country. This is consistent with the comparative lack of
preventive and curative services for health care, and active social
development processes in these districts. Of the many INGO’s and NGO’s
working in Nepal, only a handful are addressing issues of health, literacy,
agriculture and women’s empowerment in these districts. In addition to CARE
Nepal in Bajura, other agencies include MIRA, SNV-KLDP, CECI-Asia, GTZ
and LWS.
CARE Nepal set up a separately funded Primary Health Care Programme
(PHC) in Bajura in mid-1992 (later to be called the Family Health Project from
1994), with a mandate to work within the existing Remote Area Basic Needs
Project (RABNP). The PHC’s program goal was to reduce infant mortality
rates and to improve the health status of children, young mothers and
pregnant women.

The program emphasizes community-based training and extension services.
Major health activities include nutrition (focusing on vitamin A) integrated with
kitchen gardens and non-formal education, mother and child health care,
coordination of the child immunization program with Government services,
home visits, village cleaning campaigns and installation and use of pit latrines.
An evaluation of the PHC program was carried out in 1994 and many of its
recommendations have been implemented. An evaluation in 1997 showed
dramatic improvements in several areas of health behaviours and health
status. Attention to Safe Motherhood in CARE Nepal intensified with the
agreement to train TBAs in Bajura, and other project districts. Altogether 204
TBAs have received training from CARE in Bajura. Beginning in 1995, other
activities introduced related to safe motherhood were training and refresher
training of FCHVs; group trainings of mothers, young women, partners,
mothers-in-law on safe motherhood issues; individual counselling of pregnant
women; and establishment of VDC SHDK Centres.
Study objectives
The study aims to document the processes adopted by women, communities and the
project in terms of traditional and current birthing practices, and the key lessons
learned about the processes of any change. Specific objectives are :
1. To document traditional birthing practices practices
2. To understand why women adopt new birthing practices
3. To understand why women do not want to adopt new birthing practices
4. To review current project strategies related to the promotion of safer birthing
practices and to make key recommendations where necessary
5. To document the key lessons learned in the project to date on promoting safer
birthing practices
A list of key questions was also included in the Terms of Reference. These will be
tackled thematically in this order throughout this report :
• Place of delivery, and rituals connected with the confinement period
• Diet during the delivery period
• Feeding of the colostrum
• Attendance by a trained Traditional Birth Attendant (TTBA) at delivery
• Use of the Safer Home Delivery Kit (SHDK)
Some background on each of these themes is needed here to set the scene.
Place of delivery and rituals connected with the confinement period
Ritual pollution beliefs concerning menstruation and childbirth are well-
documented in Nepal. Menstruation and childbirth are considered dangerous
outbreaks of female sexuality and need to be contained and controlled.
Menstruating girls and women must go to a separate room, shed or other
place away from the house during their menstruation. Childbirth is similarly
polluting and women are again physically separated from the rest of the

household at this time. On both occasions, the return of the woman to the
normal order is marked by purification rituals and bathing. If places used for
this confinement places are dirty and unventilated, it is fair to conclude that
these traditional beliefs and practices will act as barriers to safe motherhood.
Feeding of colostrum
Much of the literature addressing breastfeeding practices in Nepal refers to the
discarding of the colostrum by various groups, particularly those in the Terai
(Singh 1998). However, most studies from hill and mountain groups tend to
show that the feeding of colostrum is more widely practiced. These
ecological/ethnic differences are also confirmed by national surveys such as
the Nepal Family Health Survey (1996), and Nepal Multiple Indicator
Surveillance Cycles I (1996) and IV (1997). This study will explore whether or
not the practice of discarding colostrum is widespread in Bajura District.
Dietary restrictions in pregnancy and the immediate post-delivery period
Again, nutritional literature refers to the common practice of restricting food
throughout pregnancy, and delivery and lactation periods in different parts of
Nepal (Singh 1998). The concept of “cooling” and “heating” foods lies behind
most restrictions. This study will explore the extent to which this is true in
Bajura, and whether or not CARE has influenced change.
Attendance of trained traditional birth attendant (TBA) at delivery
An evaluation for CARE by the Valley Research Group in 1997 reported that
the proportion of births attended by CARE-trained TBAs in Bajura had
increased from just over 1% at baseline to over 40%. Whilst the present
study will not attempt a similar evaluation, qualitative data will be collated about
community perceptions about the role and use of TBAs, and the problems and
successes of the TBAs in the VDCs visited.
Use of Safe Home Delivery Kit (SHDK)
The pre-assembled “Safe Home Delivery Kit1
” was launched by Maternal and
Child Healh Products, Limited, a private company in Kathmandu, after two
years research by the Save the Children Alliance, Nepal (1994). An evaluation
of the use and impact of the SHDK in several districts in Nepal is being
conducted by Save the Children US in association with PATH/USA : the report
is due for release in June. CARE introduced the SHDK into its health and
population programming soon after start of production. Initially kits were
suppled free of cost to Mother’s Groups and FCHV’s in project areas in Bajura
Early indications seem to be that the kit is well received by women who know
about it in Bajura but that there are problems with cost and supply. This study
will also look at the use of the SHDK.
1
The contents of the kit are a plastic sheet, three thread ties, a razor blade, a plastic dhag to use under the cord
as a cutting surface, a small piece of soap and pictorial insert for instructional purposes. These are based on the
WHO principles of the three cleans : clean hands, clean delivery surface, and clean cord care.

3. METHODOLOGY
3.1 VDC selection and general approach
A three week period was allotted by CARE Nepal central office for the field
work in Bajura. Taking travel time into account, the actual working days for
data collection in each of the VDCs was three days.
Three VDCs (Manakot, Jugada and Pandusen) were selected by CARE Nepal
central office staff for the study. The timing (Financial Year) of CARE’s input
into these VDC’s is as follows :
Phase In Phase Out
Manakot 1991 1998
Jugada 1995 1999
Pandusen 1995 1999
In each VDC, one or two (adjacent) clusters were selected for SSI and FG
sessions. These clusters had to meet the criteria of being mixed DAG and
non-DAG communities and less than two hours walk from the site office.
All interviews and discussions with community members began with a request
to describe the purification rituals (navarane or naming ceremony, and the
chokkine rites) that signal the return of the household to the “normal order”,
with the mother and her new-born baby incorporated back into the household
in an unpolluted state. Discussion then worked backwards to allow exploration
into the choice of place of delivery and the detailed circumstances surrounding
the birth. This approach was utilised in order to avoid a perception that the
study team, and CARE Nepal by association, in general may be in conflict wih
traditional beliefs about ritual pollution and religion. We explained that we had
come to study the traditional birthing practices in the area, and did not mention
evaluating CARE, nor that we were were planning to introduce any additional
intervention programmes into the area.
3.2 Qualitative research techniques
The study used qualitative techniques to collect information on traditional and
current birthing practices, and to gain an impression of any patterns of change
emerging in these in recent years. Tools developed were :
(a) Semi-structured interviews (SSI)
These were conducted with health service providers (VHW, MCHW, ANM,
FCHV, CMA, TTBA, dhami jhankri) and school teachers. The protocol for the
SSI is given as Appendix IV. Table 3.1 shows that participation from non-
DAGS providers was double that of DAG. The table also indicates that the
level of HMG health service provider personnel in post was low.

Table 3.1 Number of Semi-Structured Interviews (SSI) by VDC
Manakot
# 2, 6, and 7
Jugada
# 3, 8 and 9
Pandusen
# 2, 3 and 4
Totals
DAG Non DAG DAG Non DAG DAG Non DAG DAG Non DAG ALL
TBA 2 3 1 1 2 1 5 5 10
FCHV - 3 - 3 1 1 1 7 8
VHW - - - 1 - 1 - 2 2
ANM - - - 1 - - - 1 1
CMA - - - - - - - - -
MCHW - 1 - - - - - 1 1
Dhami 1 1 1 - - 1 2 2 4
Teacher 1 2 2 2 - 1 3 5 8
Total SSI 4 10 4 8 3 5 11 23 34
Table 3.2 Number of participants in different Focus Groups (FG) by VDC
Manakot
# 2, 6, and 7
Jugada
# 3, 8 and 9
Pandusen
# 2, 3 and 4
Totals
DAG Non DAG DAG Non DAG DAG Non DAG DAG Non DAG ALL
Grandfathers - 5 - 2 5 1 5 8 13
Grandmothers 5 3 8 7 4 1 17 11 28
Mothers 16 17 2 22 6 3 24 42 66
Fathers 4 4 8 11 5 1 17 16 33
Girls 8 2 3 12 - - 11 14 25
Totals 33 31 21 54 20 6 74 91 165

(b) Focus groups (FG)
In each of the three VDCs, the following focus group discussions were
conducted :
• Grandmothers
• Grandfathers
• Mothers
• Fathers
• Girls (from approximately age 12 to 18, without children)
An attempt was made to avoid the inclusion of active community members
very familiar with the work of CARE (e.g. mother’s groups, leader farmers).
The aim was also to convene mixed FGs, both DAG and non-DAG. It was
hoped that this could be achieved by selecting a cluster in which both DAG
and non-DAG lived, or two neighbouring clusters. This was not always
successful and separate DAG and non-DAG FGs had to be convened on
occasions in all three VDCs in order to reduce caste bias in participation. No
salaried health service providers or TBAs were included in focus group
discussions. Guidelines for the focus groups are given in Appendix V.
Table 3.2 shows that the balance of DAG and non-DAG participants in FGs
was better than that for SSIs, but again the tendency is for a lower
participation amongst DAGs. In all three VDCs, it was often difficult to achieve
a mix of DAG and non-DAG participants in the same FG which necessitated
separate groupings and accounts for the high numbers in some columns. In
Jugada, two separate areas were visited : ward 3 around Nuwakot, and wards
8 and 9 around Rajali (Gogali and Naudardo)
(d) Case studies
A case study is a research technique used to investigate in detail a
contemporary phenomenon within its real-life context (Yin 1994). In this
study, case studies were collected to provide details of childbirth experiences
and to illustrate a number of the most important issues emerging from the
other qualitative techniques. The approach was to encourage people to
recount the details of their delivery and to reflect on their feelings, both at the
time, and in retrospect. Listening, probing and prompting were utilised to elicit
more biographical details and to move on the flow of the dialogue. Cases
were chosen because they highlighted issues related to safe motherhood
practices that consistently emerged from SSI and FG sessions.
One case study was conducted in each VDC. During the planning stage in
Kathmandu, the original objective had been to identify and interview the
threshold case in a cluster (i.e. the first woman to have delivered inside the
house as opposed to the animal shed ghot). However, once in Bajura it was
realised that this was not appropriate in either Manakot and Jugada districts
where delivering in the house, or in a separate chhau ghar but not in the
animal shed ghot, had been the normal practice for a considerable time.
Alternative criteria were then applied with individuals selected for case studies
on the basis of conversations with service providers.

A brief description of the case studies is as follows :
• In Manakot, a woman who had recently delivered inside her house was
selected as the case study. She was still in chhau.
• In Jugada, a couple were identified who had delivered their first baby in
their house but it had died when it was only three weeks old. The couple
then decided to deliver their second child in a chhau ghar because of
doubts about the “safety” of delivering again inside the house.
• In Pandusen, a threshold case was identified. She was a trained FCHV
who is the only woman in her DAG cluster to have delivered in a room in
her house. Delivery in animal shed ghots is still the normal practice.
(e) Snapshot observations
These are opportunistic observations of places and interactions between
people that can precipitate further probing/clarification of themes related to the
study. Examples were :
• identifying ritual space and symbolism inside houses and sheds
• who is/is not in the house, where they can go, and who can/cannot
be touched
• supply of CHDK in commercial outlets
• state of TBA equipment
The following were proposed but not observed during the fieldwork period :
• actual time of delivery
• post-delivery purifications (navarane, chokkine din)
• any training sessions related to maternal and child health
(f) Mapping
CARE field staff, working with members of local community organisations,
developed spatial maps in each of the three VDCs (Appendix III). These maps
were used to aid in the selection of clusters for interviewing and to visualise
distance from health service providers for childbirth.
(g) Aids
The following aids were used to assist in contextualisation and interviewing :
• black and white photography of people and places
• tape recordings of FGs and cases were taken to allow
retrospective analysis and clarification of local language
• flip chart pictures depicting clean/unclean delivery (HMG TBA
training material). These were used to provoke discussion over
differences (good/bad practice), and to confirm or reject the
premise that delivery in animal shed ghots, either with the animals
still present or removed, was a common practice.

4. STUDY FINDINGS
Content analysis involved the methodical examination of field notes, interview
transcripts and observations by identifying and grouping themes and responses to
questions, and then systematically coding and classifying them. This chapter gives
descriptive summaries under common themes, with similarities as well as
differences of views, experiences and behaviours taken into account.
4.1 Place of delivery and rituals related to the confinement period
Ritual separation at childbirth has long been, and is still, practiced in all VDCs
visited. However it takes different forms depending on the type of place
available for confinement. These are summarised in Table 4.1 below :
Table 4.1. Descriptions of different types of delivery place
Place name Description Where
found
Photo
Chhau kuno
(kullo ?)
a place separated off from the rest of the house and the
fireplace by a border of stones. The area is usually
close to the door to minimise the risk of touching
anyone on exit. It is also usually located on the middle
mujelli floor of a three storey house. It is commonly
used by those with no personal chhau ghar or access
to a communal chhau ghar, but is also used by those
who do, especially in the winter months
Manakot
Jugada
Pandusen
(case)
16
Chhau ghar
(also a ghot)
a ground floor shed only ever used for menstruation,
and sometimes (though not always) childbirth, and in
which no cattle are ever housed. Can be a separate
building away from the house or attached to the side of
it. Some communities have communal chhau ghars for
several related households. A chhau ghar is
sometimes also called a ghot because it is on the
ground floor
Manakot
Jugada
Pandusen
8 9 10
11 14
Chhau ghot a ground floor shed only ever used for menstruation and
childbirth and in which no cattle are ever housed. It is
essentially the same as the chhau ghar except that it
is architecturally identical to the gai baisi ghot and is
usually adjacent to it
Jugada
Pandusen
14
Ghot
(gai baisi)
a shed on the ground floor in which cattle are kept and
where delivery also takes place
Pandusen 15

This table indicates that there could be scope for confusion over the use of the
word “ghot”.
Other traditional practices related to the place of delivery include :
(a) use of physical symbols
• stones : these are placed as a symbolic border around the chhau kuno
when the woman delivers in the house to separate her from the fireplace
and the rest of the household
• knife : a khukuri or other iron-bladed knife is kept beside the mother and
baby during confinement. This is thought to protect them from evil
influences, such as bokshi (witch)
• fishing net : this is hung above the door of the chhau ghar or ghot, or
placed near the entrance. It is used to entangle any malevolent bokshi
who may wish to enter and harm the baby or mother
• basket : an upturned open-weave basket is placed at the entrance to the
delivery room, and serves the same purpose as the fishing net
(b) purification rituals during the period of confinement
navarane
This is the Hindu naming ceremony. All respondents consistently reported
that it took place on the 9th day after birth for a daughter, and the 10th day for
a son, although these might vary if particular days were inauspicious. Until
this day, no-one is supposed to touch the new mother or baby. In high caste
groups, the navarane ceremony is performed in the house by a Pandit
(Brahmin). In low caste households, pre-menstrual girls (konyani keti) or a
maternal uncle perform the thread giving (wrapped around wrist and waist)
and spraying of cow’s urine. A member of the household will then go to the
Brahmin’s house bearing rice grain and money to pay for blessing services.
On navarane day, the baby and mother bathe and wear fresh clothes, and the
delivery area and other parts of the house are newly plastered (lipne).
chokkine din
This is the day in which the woman and her baby are returned back “cleansed”
into the household and the normal order is restored. After this day the woman
can cook food and touch water as normal, eat alongside other family
members at the same fireplace and touch others. There was some
disagreement over when the chokkine takes place, with responses ranging
from 11-15 days in younger groups, to 25-28 days amongst dhamis. The
general concensus appears to be that the minimum is 11 days, and the
average is about 22. There were comments from both young and old that the
length of chokkine period has been decreasing in the last decade, and that it
depended on the work load of the woman and the need to return to domestic
and agricultural labour. Many agreed that the enforced rest during the
chokkine period was a good thing for the mother and her child, and expressed
concern that speedy return to a heavy work load would detrimentally affect the
health of both mother and baby.

There are fewer rituals connected with chokkine, and the priest is not always
called. Generally the cleaning of the fireplace, making of roti, lighting the deva
lamp, bathing of all family members, cleaning and plastering the house and
spraying cow’s urine over house and on newborn and mother are the
necessary procedures for “bulla chokyo” (really cleansed).
There are almost no differences between high and low caste communities,
apart from the calling of the Brahmin. Interestingly, the immigrant Buddhist
Bhote people have also adopted most of the Hindu practices for delivery place
and confinement, but sprinkle holy water from the sacred Manasarovar Lake in
Tibet instead of cow’s urine, burn incense, and call a lama instead of a
Brahmin priest.
Are there signs of change ?
The expectation for this study had been that there would be signs of a change
in the place of delivery, and a shift from the animal shed ghot to the house,
since the intervention of CARE in the area (see Terms of Reference Appendix
I). However, this study was unable to demonstrate this in two out of the three
VDCs visited.
In Manakot and Jugada the place of delivery has changed little in several
generations. As before, delivery either takes place in the family chhau ghar or
in the mujelli floor of the house with its stone border. The size and style of the
chhau ghar varies and depends on space for construction and money. The
practice of delivery in animal shed “ghots” had not been common in either
Manakot nor Jugada for many years, and had certainly changed well before
CARE’s arrival (older people could not recall a case). The situation was
different in Pandusen. Delivery in animal shed ghots was, and still is, a
common practice, especially amongst DAG groups. High caste Chhetri,
Brahmins and Thakuris tend to have more space and a small lower floor room
(often also called a chhau ghot) for childbirth.
It has not been possible to show any impact of CARE in this part of birthing
practices. However, investigation of these issues has exposed ambiguity over
the word ghot which may have led to misunderstandings about the extent of
the practice of delivering in animal sheds, and thus to the expectation
expressed above (see chapter 7 : Lessons Learned).
The physical symbols used in the period of confinement and the rituals to
mark the end of the “unclean” period have little changed over time.
However, positive change was clearly demonstrated in an increased
awareness of cleanliness for the delivery area and the use of mud alone to
plaster rather than a mixture of mud and cowdung. This was attributed to the
influence of CARE’s cleanliness campaigns. Many younger people and
parents of non-DAG communities were able to explain how dirt and cow dung
in the delivery area could lead to infection and sepsis. People reported that
they now cleaned the delivery area before delivery, and not just afterwards, as

hey had done before CARE. However, DAG communities appear to either be
the least receptive to this message, or have heard about it less. Some
attention is needed to address this.
4.2 Diet during delivery period
The traditional diet during this period was restricted, at least until the 6th day
(Chaitya) after birth, and quite often throughout the whole chokkine period.
Only dry foods, such as millet and barley roti, litho and rice, fried in oil or ghee
were considered suitable. Grandparents also mentioned honey as a good food
during the delivery period but lamented that the loss of forest has been
accompanied by the loss of bees. Traditional food beliefs categorise wet foods
and liquids as too “cooling” and foods containing spices as too “heating”.
Some older people, though by no means all, reported that no salt was fed to
women during delivery as it was believed to cause fever.
Although some believed that sag and green vegetables cause fever, diarrhoea
and oedema in the baby, many admited that these had never been part of the
normal diet in the past.
“The only green thing I saw during pregnancy was sisno
(nettles).”2
Both in the past and today, a very strong prohibition exists for the consumption
of milk, buttermilk and cream (termed collectively as goros), the pure products
of the cow, and often the buffalo, until after the chokkine din.
“Even if you were in delivery and about to die, I would not give
you milk”3
With the cow regarded as sacred, and milk regarded as a “reincarnation of the
god Krishna”, and the newly delivered woman considered as “unclean”,
replies to the question “do women in confinement drink milk” were almost
always met with expressions like :
“deuta bigrincha, deuta sahardeyna, hamro chalan cheyna, gai
baisi bigrincha”
(the gods will be harmed, are offended, it is not our custom, the
cattle will be harmed)
Such remarks would come as frequently from health service providers such
as TBAs and school teachers as they would from other people. When asked
what would happen if milk were to be drunk, the reply would usually be that the
cattle would get sick, stop producing milk and become sterile. Then the dhami
would have to be called, and a sacrifice made to appease the offended gods,
for things to be put right.
2
Grandmother from Manakot
3
Father from Jugada

From responses to SSI and in FG discussions, it is clear that CARE has had
considerable impact in raising people’s awareness and knowledge about a
varied, better quality diet during pregnancy, delivery and lactation. Most
people, even the older ones, were able to list the foods that were good for
child-bearing women. They usually also said “we have learned this from
CARE”.
People particularly mentioned dark green leafy vegetables, other vegetables,
pulses, meat and fruit. Non-formal education on nutrition and kitchen
gardening activities were cited as the main agents of this change.
“In my time, I had never seen cauliflower, sag, radish or
cabbage. Nowadays, we can see them all in season. After
CARE, we give everything to women (in delivery). In my day
there was nothing much anyway.”4
However, this study did not evaluate whether such reported knowledge is
translated into action and leads to the feeding of a better diet to mothers during
the delivery period. Quantitative investigation is needed to confirm this. For
women delivering now, it is hard to see how this knowledge could be acted
upon given the current food situation in Bajura.
4.3 Feeding of colostrum
Routine discarding of all of the colostrum was never a very widespread
practice in the three VDCs visited. Although some older women did mention
that some of their mothers-in-law might tell them to do so, others argued that
their mothers-in-law had told them the reverse. It appears that it was mostly
a case of feeding in ignorance of what to do at all rather than feeding because
it was thought to be a good practice. There was also the feeling that it was a
good option to have the baby sucking at the breast, whatever may be coming
out. A few older women did express the belief that colostrum causes
diarrhoea (“pet karab huncha”) and fever in the newborn.
Most women reported putting the baby on the breast after they had cleaned
the baby, which seemed to be usually within the first few hours of birth. The
study did find that women tend to express the first drops of any milk feed
(colostrum as well as full milk) to check that there is milk there, and to discard
the first drops which may be “dirty” in the nipple. However, this is not the
same as discarding all the colostrum and will have far less serious nutritional
and immunological consequences for the child, and may even act as a boost
to tthe mother’s confidence that she does produce milk.
Both younger and older women showed considerable awareness of the
importance of immediate breastfeeding and feeding all the colostrum. Again,
all respondents attributed this knowledge to the educational efforts of CARE.
4
Grandmother from Jugada

However, as discarding of the colostrum appears never to have been a
serious problem here before CARE arrived, the behaviour change issue is
largely redundant.
4.4 Attendance by TTBA at delivery
In the three VDCs of this study, there was no traditional practice of calling an
outsider into a household to help deliver a child. Most older women stated
that they delivered their children with the help of a close female relative such
as their mother, mother-in-law, aunt, sister or sister-in-law.
There are certainly more people today who call a TBA than there were a
decade ago before CARE had arrived and implemented the TBA training
programme. However, without a detailed evaluation it is difficult to estimate
the extent of the change. CARE field staff suggest, that in the VDCs in which
the study was conducted, there is about a 50% rate of call up5
. Many people
admit that they only resort to calling a TBA if there is a problem, or if there is
no-one else in the family around. Thus there is still plenty of scope for
improvement.
Reasons for not adopting the new behaviour have emerged from the study :
• there is no tradition of a TBA which means that mothers-in-law and
older people are often unreceptive to the idea, if proposed
• there is still a strong belief that it is risky to let people outside the
household know when a woman is going into labour. People perfer
to keep the news quiet for as long as possible for fear that it might
reach the bokshi who will then come and try to do harm to the
mother and newborn6
• there may be no suitable TBA nearby (a high caste TBA will rarely
attend a low caste delivery, and vice versa)
• the personality and commitment of the individual is important. The
community is well aware which TBA is working sincerely and
effectively and which is not. The level of respect given to the TBA
by the community is a key factor. It varies greatly in all VDCs.
• there is no perceived advantage of calling the TBA over a relative
because all the TBA does is massage, cook food, and give
instructions - once the baby is out, she does not touch the
mother, to cut the cord, tie the threads or expel the placenta,
except in an emergency, and sometimes not even then
“No-one will touch, even if the mother is about to die” 7
5
Sunita Shirish Thapa, personal communication
6
this also means that people prefer not to leave a woman alone at night during the confinement period. A relative,
even the husband, will sleep in the same room
7
Mother from Jugada

This is due to the strong beliefs of ritual pollution :
“Once we touch we also become “untouchable” and would have
to say in chokkine with the mother. Obviously we can’t do this
because we have our own work to do and our own families at
home.”8
There is fear that the harmful “fall-out” of touching in chhau may not happen
immediately :
“Just like it takes a long time to boil water, it may take a long
time for the bad effect (of touching in chhau) to come” 9
Breaking this rule would also probably entail the expense of a sacrifice to
appease any offended gods. This is not a belief that people dismiss lightly.
However, there is cause to be optimistic. An active and respected TBA from
Manakot believes that about a quarter of all TBAs in her VDC are beginning to
touch, and that resistance is waning. Many community leaders and school
teachers in all the VDCs studied remarked that :
“it is just a matter of time”
They believed that the next generation of mothers and fathers would see this
belief subside enough to allow TBA direct assistance at most births. They
also suggested community discussion groups of all generations to question
the boundary between not touching in normal circumstances and touching in
an emergency as the best place to start.
4.5 Use of SHDK
Traditional birthing equipment for cord care was simple. All that was needed
were a hasiya (sickle), other knife or even a stone to cut the cord, something
to place under it as a cutting surface such as a piece of wood, and a piece of
thread from material or a home-made string of bhangro (hemp) to tie the cord
in one place towards the baby before cutting. There was no knowledge about
the need to clean any of these items and as a consequence a large number of
maternal and child deaths resulted from tetanus, sepsis and other infections
from such dirty conditions.
8
TBA from Manakot
9
Grandfather in Jugada

The arrival of the SHDK, and its promotion and distribution through CARE’s
activities in Bajura, has brought a considerable increase in the level of
awareness as well as actual behavioural change. CARE is so closely
associated with the SHDK that many people even refer to it as “CAREko
saman” (CARE’s equipment). (see Sappata Thematic from PIR ??)
Those that have learnt about it are predominantly women and include mothers
as well as grandmothers. Women using it by themselves, and TBAs who
bring it to deliveries, agree that it is “sajhilo”, easy to use and there is nothing
to get ready. There is less concensus on whether or not it is cheap.
“It’s not necessary to spend even 15 Rs/- when there’s a
hasiya already here in the house. It costs nothing and was
always used before.” 10
Whilst some complain that they can’t afford it at all (predominantly the DAG
respondents), others argue that the cost is reasonable and that it is well worth
paying.
“We should buy it. It’s not much. It’s for our family and why
should we get it for free. We pay for Jeevan Jal - it’s the same
thing” 11
One woman was so impressed with it that she suggested that it should be
included as part of a woman’s marriage dowry ! Another remarked :
“I didn’t use it for my first grandchild because I didn’t know
about it then. But I’ll use it for he next, if I don’t die first”
What emerged from discussions with men was that they generally revealed a
much lower level of knowledge than women of the CHDK. These male
sessions ended up being a SHDK demonstration rather than a discussion on
current knowledge about the product (see Photo 7). This needs to be
addressed as it is often the husband or father-in-law who will make a decision
on what family money is to be spent on. Creating demand amongst men as
well as women is necessary.
There is clearly a supply problem for the kits. No sustainable supply was
encountered in the areas covered by the study. The role of Community
Development Organisations and the SHDK Centres appears crucial. Where
there is an active CDO, such as in Manakot, the demand for, and the supply of
the CHDK seems promising. albeit mainly in the non-DAG clusters. However,
the CDO gets the supply from Nepalgunj because there is no reliable supplier
in Martadi (not even the hospital), and there are still difficulties with the
establishment of a revolving fund. In other areas where there is no active
CDO, the supply of the kits is dismal and needs urgent attention. Where
available, the cost of the kit varies from 20 Rs/- (from TBAs using their original
supply but not as a revolving fund) to 40 Rs/- from a pharmacy in Martadi.
10
Man from Pandusen
11
Man from Jugada

5. CASE STUDIES
Whilst the previous chapter has presented study findings from a theme-based
perspective, this chapter looks in detail at the responses of particular individuals to
issues of birthing practice.
CASE 1. Behind the stone border : a home delivery in Manakot
Chandra Rokaya is a Chhetri woman in her early 30’s. She lives in
ward 6, Manakot district and was interviewed in her house six days
after the birth of her new daughter. The plastic sheet from the CHDK
was visible under the baby’s blanket. Chandra was sitting in an area of
a room in her house separated off by stones (see photo).
“I had two pregnancies early on in my marriage but I miscarried both times before 6 months
term. In 1988, I delivered my first child, a son, in my maiti ghar (parents house). I had gone
out to cut grass and my labour pains began. I came back to the house. My mother told me
how to prepare the chhau kuno area by placing a border of stones around me to mark the area
where no one else could come, and to separate me from the fireplace where the food is cooked.
I don’t need to put stones on the side where the door is - then it is easy for me to go outside.
But I have to walk with my head bowed and be very careful not to touch anyone with my clothes.
While we are in chhau no one can touch us, not even our other children. We also can’t touch
them. My food is cooked for me and given to me in a separate bowl that I keep upturned in the
chhau kuno, behind the stone border. I also used this bowl for washing my hands during the
delivery and the placenta was put on this and then taken to be buried outside.
There was no time to clean the area as almost immediately the baby was born. I cut the cord
with a hasiya, holding a piece of wood underneath, and tied the cord in one place wih a piece of
thread from my blouse. My mother gave me advice on what I should do. I had not cleaned the
hasiya nor the thread before using them. I had not heard about any injections during my
pregnancy, or TBAs, or the sutkeri samagri at that time. I breastfed my baby straight away,
only pausing for a second or two to clean the nipple. During my time in chhau kuno I ate only
roti and ghee. My mother told me tha if you eat too much rice whilst you are in chhau the baby
will be scarred. I was not allowed any other food, not even salt which my mother and mother-in-
law said would cause fever in they baby and scar his face. We don’t give salt to anyone who is
ill. We never eat milk or yogurt because if we do the gods will be angry and the animals will
get sick and sterile.
While I am staying in the chhau kuno, I must keep a hasiya by me at all times as protection
against bhot and bokshi. When I go to wash at the separate chhau dhara, I carry it behind
me, tucked in to my potuka. When I go to wash I leave the baby alone in the house wrapped
up in a blanket.
I delivered my first daughter in 1993 in the same way, except that I was in my marital home and
not my maiti, and it was my mother-in-law that helped me and not my mother. After each of my
deliveries I did not menstruate again for 3 years. When I do menstruate (sano chhau) I make he
same place for myself in the house as I did for the deliveries, using stones as a border and
washing at the chhau dhara and not the normal dhara. I stay in sano chhau for 5 days.

I have just given birth for the third time, and now have another daughter. This year there has
been very little food. Whilst I was pregnant I have eaten mostly pidalo litho and roti, although I
now know that I should be eating more than this and especially bhat, roti, dhal and vegetables,
as CARE have been saying. But I don’t have all these things - what to do ? For the first time I
took an injection during this pregnancy as I was told to by the FCHV. I don’t know what the
injection was for.
I had learnt about TBAs from CARE Nepal’s non-formal education classes and from talking to
other women. I heard that TBAs had been trained by CARE and that they would help do a clean
delivery. Also my mother-in-law had died and would not be around to help in the birth and as I
didn’t want to be alone I decided to call the TBA. She heated oil to give me massage during
the first stage of labour, and she examined the position of the baby. She also cooked my food.
She brought with her an SHDK and showed me what was in it. I had heard about the SHDK
from CARE but I had never seen one. The TBA said that she would cut the cord for me but I
told her I would do it. No one is supposed to touch us once the baby is born and anyway I
knew that cutting the cord myself wasn’t difficult as I had already cut it twice before using a
hasiya. It was much easier to use the blade. With the hasiya I had to saw a bit, but with the
blade it was a single clean cut. I was happy with the help I received from the TBA. But I didn’t
give her anything for helping me - she receives training and other things from CARE.
My husband did not help in any of my deliveries. He was even shy to pick up his son when it
first came out of chhau. Men are not involved in such things.
According to CARE staff, Chandra had not been not active or vocal in
any of the groups that were established whilst CARE was working in
Manakot. However, she still changed her birthing behaviour in this
latest delivery by calling a TBA, using the CHDK, and taking an
tetanus injection whilst she was pregnant. She was also aware of the
need to eat a better diet but felt unable to do this because there was so
little food available to her. The place of delivery stayed the same,
inside the house. Her belief in the no touching rule also remained -
she insisted on cuttig the cord herself even though the TBA offered to
do it for her. We should exercise caution in attributing Chandra’s
changed behaviour solely to the influence of CARE. The death of her
mother-in-law before the most recent pregnancy may also have
enabled Chandra to make her own, different, decisions about the birth.

CASE 2. Bad luck and behaviour change : from house to chhau ghar in
Jugada
Duble Bahadur and Phugi Rokaya live in ward number 8, Gogali
cluster, Jugada VDC. Duble is 26 years old and works in a hotel in
Martadi, about an hour’s walk away. He has passed SLC and has
joined certificate level with the second year still to complete. Phugi is
24 and has only basic literacy skills. She also works in Martadi as a
peon in a government office. They have been married for four years
and have one son, aged 20 months old. Another son had been born
three years ago but he died soon after birth. This is their story :
Phugi :
“My father-in-law told me to deliver my first baby in the mujelli (middle) floor of the house. He
had travelled a lot and seen and heard many things, and he thought that the house would be a
good clean place to have a baby. I also liked the idea myself. The normal practice here is to
deliver in a separate "chhau ghar". I was not the first in this family to deliver inside the house.
My mother-in-law had also done so, as had my sister-in-law four years ago.
When I was 6 months pregnant with the first baby I started to get pains and these went on until I
delivered a baby boy at 8 months. My mother-in-law helped me deliver the baby. I cut the cord
myself. I counted two finger widths from my stomach, tied a knot with string and cut the cord
with a hasiya – the sort we use to cut grass and leaves. I didn't know any better then and no
one told me what else to do. It was a normal delivery and everything seemed fine at first. But
after a few days the baby began to develop sores in his mouth, didn't feed, got thinner and
thinner and cried day and night. I also had bleeding, stomach pains and lost weight. I took
some medicine but it didn't help. On Chaitya, the sixth day, my husband was bringing roti and
hot ghee to me from upstairs when he tripped and scalded his hand. My sister-in-law also fell
down the stairs. Meanwhile, the baby was getting worse, he couldn't feed and he cried all the
time - he wouldn't stop for a second. It was very difficult for me. The baby died when he was 20
days old.
At that time no one spoke about a connection between the baby dying and delivering in the
house. But after a while one cow and one buffalo became sick and sterile and my mother-in-law
went to see the dhami jhankri. The Maru god spoke through him in possession and said that by
delivering a baby in the house we had offended him and that we had polluted the house. In order
to cleanse it we had to call a Brahmin to do purification "juggiya" puja and spray cow's urine
over the house. The god also said that the next baby should not be born in the house. We all
believed that we had offended the gods.
I got pregnant again after 6 months. This time my mother-in-law took me to deliver in a chhau
ghar at an uncle's house, where there was no statue of the god. What to do – I had to do as I
was told. I would have preferred to stay in my house for the second birth but I was not allowed
to. My own house would have been cleaner, more convenient and more familiar. There would
also have been more privacy. In my uncle's house a lot of neighbours came to look at me and
they might have brought a bokshi (witch) that would have harmed the baby or made me lose my
appetite.

I got a CHDK from a TBA who had recently been trained by CARE. I tried to persuade my
mother-in-law to call the TBA when I went into labour but instead she called a relative
(chairperson of the mother's group) who gave me massage during the firsl stage of labour,
helped prepare food, and gave me ayurvedic medicine. The delivery was normal although it was
more difficult than last time as the baby was a lot bigger. My mother-in-law told me what to do
from looking at the drawings in the CHDK. I washed my hands, tied the cord twice with the
string and cut the cord with the blade. I found it much easier to use the blade than the hasiya
and by then I had also learnt from CARE that the hasiya can cause infection.
Nothing bad has happened since this birth. The boy is fine. But I think my first baby died
because it was sick, not because I delivered in the house”.
Duble :
“I agreed with my father that my wife should deliver the first child in the house, in the mujelli
floor. The top floor wasn't appropriate because we keep images of the gods there. But I thought
that the chhau ghar would be cold and damp, and that my wife would be more comfortable and
relaxed in the house where everything was familiar and there would be people nearby to help
her. When labour started in the night, I was nervous and called my mother. She took my wife
downstairs to the mujelli floor. We didn't call anyone to help. My mother was there. I think my
wife cut the cord herself but I didn't see – I stayed upstairs. We have a custom not to touch the
newborn and mother after the birth. If you touch then "deuta bigrincha" (the gods will be
offended). That's the custom. If you touch you will be sick.
When I scalded my hand on the sixth day I took it as a sign of bad luck. Then after a few days
the baby started to become sick. My wife's milk also dried up. Some other people started to
speak that I shouldn't have delivered the baby in the house and should have followed the normal
custom. The baby became worse very quickly and then he died – I don't know why. We began
to think that what happened to us and the first baby proved that we had done the wrong thing.
So for the second pregnancy my wife went to my uncle's house where there is a separate chhau
kunda at the side of the house. I don't know what happened during this delivery as I was in
Martadi. I only came home when the baby was 10 days old.
This second boy is fine. He hasn't been sick very much and we haven't had to spend much
money on medicine for him. And his mother has plenty of milk this time. I have been thinking
more and more that we should stick to some of our traditions but that we should get rid of some
of our taboos, though not those that go against our religious beliefs. I still believe that it is
better to have the baby in the living part of the house than in a "ghot" on the ground floor or a
"chhau ghar", but not in any house where there is a god. Delivering in another house will not
have such bad effects.
We had bad luck with the first child but it's also probably because we shouldn't have . had the
baby in the house with the god. I still have regrets about that decision”.
This case study highlights the depth of the traditional beliefs in place of
delivery which persist even amongst those of above average
educational level. It also highlights the importance of influencing
individuals as potential agents of change (father, mother-in-law) and

the persisting belief in recourse to the dhami jhankri in the face of
calamity. Gender inequities are articulated by Phugi as she complains
about her own powerlessness in the face of decisions made by other
household members.
CASE 3. A threshold case of home delivery from a DAG community in
Pandusen
Bhidi Kadara is about 35 years old, has basic literacy skills and is
trained as an FCHV. She lives in ward 2 in Samalgaun, Pandusen, not
far from the CARE site office. Her husband is a peon at the health
post and studied to class 6. Bhidi had three pregnancies and all these
children have survived.
I married at age 17 and had my first child, a daughter, when I was about 18. I delivered the baby
in the animal shed ghot underneath the house. We moved out the cattle and plastered the walls
and the floor with cowdung and mud. I started labour at about sunrise and delivered the baby
early in the afternoon. My mother-in-law and husband were there too. My mother-in-law
massaged me and told me what to do. She handed me the sickle and told me how to cut the
cord and I tied the cord once with a piece of thread from my clothes. I put the baby on my
breast straight away. I didn’t throw away the colostrum, although I did express a bit first to see
if I had any thing at all and just to let the baby suck to keep it from crying. After 2 days my
white milk came. My husband cooked my food and brought it down to me everyday until the
purification chokkine day. Then we brought the animals back into the shed. At that time there
was no CARE Nepal and no Women’s Development programme.
It was a long time before I conceived again. We were all concerned about this and eventually
my mother-in-law went to consult a dhami jhankri. He said I was not bewitched and that I would
eventually, when the planets were right, we would have another child.
Shortly after CARE came to Pandusen, I delivered my son. It was a short labour, only 4 hours.
I had already got the animal shed ghot ready, it was nice and newly plastered. But then my
husband decided that I should deliver the baby in the house, in a room on the middle mujelli
floor. My husband was working as a peon in the health post by then and said he had learned
more about being clean and preventing sickness. He said that nothing will happen if you have
the baby in the house, and anyway if it did all they had to do was sacrifice a goat. He said that
the rest of the family would eat upstairs and that I would be more comfortable in the house.
When I said that other people might speak against us, he said that it was not their business
what we did in our own house. My mother-in-law didn’t disagree so that’s what happened.
CARE staff had also been saying to people that it was dangerous to deliver a baby in an animal
shed ghot because both mother and baby could be sick. I had also been to a Mother’s Group
workshop at the health post and that time I had learnt about the CHDK. So I bought one for
Rs/- 20 and used it myself.
I was the first person in Samalgaun to deliver in the house. There are about 40 other
households in the village but everyone else delivers their babies in the animal shed ghot. Some
other people did speak that we should have delivered in the animal sheds and tha the gods
would be angry, but we didn’t listen to them and nothing happened.
My third child was born 18 months ago and is another boy. He was also born in the house, and
I didn’t bother to prepare the ghot. I had got the knowledge and the confidence from my training
with CARE. I cut the cord myself with a blade from the CHDK which CARE staff had given me
in the safe motherhood orientation which I did while I was pregnant. I tied the cord twice. I

didn’t call the TBA. We don’t have a habit of calling anyone or even letting anyone know that
someone in the house is in labour. We don’t want to risk a bhut or bokshi getting to know and
coming to cause trouble. We keep it private and only call a close relative or close family friend.
No-one else should know until after the baby is born. But we don’ say alone in case the bokshi
comes - at all my deliveries mu husband and mother-in-law were with me.
I have tried to teach women here that having babies in the animal shed ghot is the old way and
they should change to the newer cleaner way. But they won’t listen. Now I have nearly given
up trying to persuade other women here to deliver in the house. Now I concentrate instead on
encouraging them to clean the ghot and not to use cow dung as plaster, but to use only mud.
Or sometimes I try and persuade women to have their baby in the separate chhau ghar which
they have for sano chhau and which is often cleaner than the ghot.
People say to me “it’s alright for you. You have more space and you can also afford to buy a
goat to sacrifice to the gods if something goes wrong, but we can’t.” They are worried about
having to spend money for sacrifices to the gods. They also they complain that their houses
are too small and have straw, and not slate, rooves. This means that they have to keep their
fireplace in the mujelli floor and not on he top floor because of the risk of fire, so then they say
that they cannot use the mujelli floor for childbirth.
But I believe that change will come eventually. Just like other things have changed since CARE
came and since the women’s programmes started, things will change.
As each delivery is described, this case highlights the influence of
CARE (FCHV training, women’s development programmes and safe
motherhood orientation), which all combined to effect this woman’s
knowledge about safe motherhood practices and the confidence to act
in a new way. Her husband was also a catalyst for change and her
mother-in-law was not a strong barrier to new ideas. However, the rest
of the village still resists change in the place of delivery, due to fear of
angering the gods through pollution, and of having to pay for their
appeasement. This case also clearly describes feeding of the
colostrum and the practice of expressing a little of each feed which
may have led to misunderstandings about discarding of the colostrum.

6. STUDY STRENGTHS AND LIMITATIONS
6.1. Strengths
The combination of SSI, focus groups and case studies has allowed for in-
depth exploration of different aspects of birthing practices from a number of
different perspectives. One of the special strengths of this combined
approach is that it frequently shows the limitations of conventional wisdom,
particularly incorrect stereotypes of life and activities which have often affected
development activities in the past.
CARE field staff facilitated SSIs and FGs, and introductions into the
communities. The trust and rapport that has been built up by these field staff
is considerable and their influence on this study should not be underestimated.
The breadth of good quality data collected in this study is largely due to their
skill.
6.2. Limitations
Taking travel time into account, the actual working days for data collection in
each of the three VDCs was only three days. This is a relatively short period
of time for outsiders to conduct qualitative research on a potentially sensitive
subject.
The timing of the study coincided with a busy agricultural season with the
harvesting of wheat and barley, and the preparation of fields for the next crops.
This may well have influenced some people’s ability and desire to participate
in the study. Unfortunately, all times of day were inconvenient with such a
heavy work load.
Although Nepali is the language spoken throughout Bajura, people have a
strong local dialect. This may have influenced comprehension at times,
although we were accompanied by CARE field staff familiar with the local
dialect during all sessions. Tape recordings which could be replayed,
transcribed, and used for retrospective discussions to elicit clear meaning,
probably further minimised the effects of language.
The results of this study should not be used to represent the picture of birthing
practices throughout the district of Bajura. CARE Kathmandu staff selected
Manakot, Jugada and Kolti VDCs for the study, on the basis of the timing of
CARE’s arrival and phase out, and logistical and time constraints. However,
discussions with CARE Bajura field staff in both Kolti and Martadi revealed that
there are significant ecological and cultural differences in the district. The
western side of the district, extending to the borders with Achham and
Bajhang, experience relatively higher rainfall than the side towards Kolti. This
has an effect on the type and extent of subsistence agriculture, and
subsequently nutritional and health status.

The two sides are also “divided” by a substantial lekh. The communities on
the Kolti side are also influenced by geographical proximity and familial
allegiances to the neighbouring districts of Mugu, Jumla and Humla12
.
The presence of outsiders may have led to expectations on the part of study
respondents13
. Even though we were careful not to emphasise our
involvement with CARE, our presence in the company of CARE staff may
have influenced people’s understanding about the questions we were asking
and biased their responses. It is difficult to evaluate the extent of this.
12
Some VDCs had even been parts of the kingdom of Jumla in the past
13
In Manakot, several people confused our visit with that of the President of CARE who had been expected about
that time.

7. LESSONS LEARNED
This chapter addresses some of the key lessons that have emerged out of this study
of birthing practices in three VDCs of Bajura District. The first two are general
lessons which are general, by no means new but which benefit from periodic
repetition. The others are specific to birthing practices and some key questions of
this study.
7.1 Assumptions and definitions
As well as providing valuable contextual information, the incorporation of
qualitative research methods into development work is increasingly being
used to improve data qulity and as a means to control for error. In attempting
this qualitative look a birthing practices in Bajura, this study has exposed
such an error : the word “ghot” is widely used but poorly understood.
CARE central staff, and consultants working for CARE14
, have written about
delivery in ghots without sufficiently investigating what the term ghot
meantwhich has led to a misunderstanding about the etxent of this harmful
delivery practice in Bajura District. At the debriefing-feedback session in Kolti
at the end of the study fieldwork, it was the office-based Bajura staff who
defined a ghot as an animal shed, whereas the community extension workers
were well aware of the different types of delivery location, knew that the picture
was more complicated and that a ghot could mean a number of things and
had a variety of functions. However, they had never been asked specifically
about this and felt that they had no forum in which to articulate the issue.
At the beginning of this study, there was an assumption that almost all
deliveries in Bajura took place in animal ghots. The reality found was that :
• there are ghots in which babies are delivered which are never used
to house animals
• there are some areas of Bajura where deliveries in animal shed
ghots still commonly occur but, with the exception of Pandusen,
these were mostly in VDCs not selected for study
This raises an important issue relating to assumptions and generalisations
made about a practice without sufficient ethnographical investigation,
both at baseline, and as interventions proceed. It also indicates that
communication between central and field-based staff could be improved to
identify such misunderstandings before they become “institutionalised”.
14
this probably also applies to other agencies too

7.2 Belief, knowledge and changing behaviour
Belief and knowledge are different. Belief can be defined as “opinions or
convictions based on the individual’s own world view”, whilst knowledge is
“used to indicate an appreciation of fact, often imposed from a different world
view” (Jackson and Jackson-Carroll 1994). Both belief and knowledge need to
be addressed to bring about sustained behaviour change.
Developmental organisations such as CARE commonly focus on efforts to
change behaviours deemed “unhealthy” or “unsafe” using education based on
“facts” to modify “beliefs”. But this approach is sometimes in danger of
overlooking the social context, the power of social pressure and of maintaining
the “status quo”. This is important in helping us determine the normal
household response to childbirth in a Bajura household. Without taking these
into account, knowledge alone will not lead to any concerted change in
behaviour in the long term.
For example, it is conceivable that someone might not believe in “deuta
bigrincha” (the gods will be harmed, offended) and may have absorbed “gyan”
(knowledge) about safe motherhood, but will still deliver a child in the chhau
ghar or ghot rather than the house, and restrict certain foods, just to remain in
social harmony with the rest of the community. To be seen doing something
different is a risky business. Performing normal childbirth routines fulfills
social expectations and sustains social cohesion at an anxious time. When
Buddhist Tibetans migrate and settle in Bajura they outwardly adopt Hindu
concepts of pollution and segregation in childbirth to be less alien from the
host society. However, interestingly they do keep the most symbolic,
innermost, practice of using Tibetan holy water to purify they house rather than
cow’s urine.
Knowledge, such as education on safe motherhood practices, is imparted at a
point in time. Unless it is nurtured and emphasised, it runs the risk of being
swallowed again by belief, especially where there is very deep-rooted belief. In
a sense this is what happened to Case Study 2 in whom confidence in
knowledge broke down. Belief had not been replaced permanently by the
knowledge, which had merely taken an upper hand for a while until it was
dislodged at the first sign of trouble.
Does knowledge lead to changed behaviour ? Sometimes, but not always.
CARE-imparted knowledge about good maternal nutrition, feeding all the
colostrum, cleaning the delivery place, and using the SHDK has changed
behaviour to some degree. However, this study has also found that neither
knowledge in the community about the existence of trained TBAs, nor the
knowledge of the TBAs themselves, necessarily leads to the widespread
utilisation of TBAs for normal delivery. Various beliefs act as barriers to
knowledge about TBAs leading to behaviour change. The most fundamental
barrier to behaviour change in this case is the ritual pollution belief concerning
separation and the no touching rule.

Who is resisting the change ? Just as it is important not to assume that a
word, in this case ghot, always has the same meaning in all contexts, it is
important not to assume that resistance to change will come from a particular
place. A reasonable expectation might be that the older generation are more
set in their ways, more rooted to tradition, and more resistant to new ideas
than younger people. Whilst in this study this was generally found to be the
case, results were sometimes surprising. One of the most positive
proponents of change was an elderly man in Manakot :
“Whatever good habits will come we will take them and not give
them up. It might not come quickly, but it will surely come. If I
learn something new to save the life of a member of my family,
and if I tell 5 people and they all tell 5 people each and then in 5
years everyone will know. This is how change spreads. But if I
only tell one person, or only talk about it with my wife, it will take
a long time”.
One of the most vocal resistors of behaviour change related to birthing
practices was a 40-year old community leader and previously CARE-
employed overseer, also from Manakot. When asked about whether or not
TBAs would ever be allowed to cut the cord at delivery, he retorted :
“No, no, no ! This will never happen. We can learn new skills,
but in terms of our devi deuta, we can never abandon our
beliefs”
“It is only a matter of time”. Harmful attitudes and practices do need to be
changed but this type of change is slow. Whilst CARE can show significant
infrastructural change and demonstrate success in training, treatment and
rehabilitaion, group establishment and kitchen garden activities, the current
policy of phasing in and out of a VDC in less than 10 years is generally not
conducive to fundamental behavioural change in the field of preventive health,
and against such deep-rooted beliefs such as ritual pollution. Acknowledging
a more realistic interpretation of the processes of change may require a longer
term involvement to allow for time for behavioural change to plant deeper
roots.

7.3 Safe motherhood as a gender issue
One of the key factors acting as a barrier to safe motherhood is the low level
of women’s status.
“Women’s powerlessness and unequal access to resources
set the stage for unsafe motherhood even before pregnancy
begins”. “Maternal mortality is a social injustice”.
These are two statements from the Inter-Agency Group for Safe Motherhood
(1997). In its work in Bajura so far, CARE has mainly considered safe
motherhood as a health issue. But empowering women to ensure they have
choices that affect their own bodies is a key gender issue, and one that needs
to be addressed in parallel to the health issues that are raised.
Does a man in Bajura ever have to endure segregation at any time, or avoid
being touched, even by his own children ? No, never. Physical segregation
of women from the household at childbirth is a gender issue. In this sense,
the place of delivery aspect of safe motherhood is fundamentally a gender,
and not a health issue, as it is related to the low status of women and their
submission to the control of men in a patrilineal society. The male is
inherently superior and inherently pure, in opposition to the inherently impure
and inferior female. External control over women’s reproductive activities is
effected by supernatural beliefs, and these are fully internalized by the women.
Their ever-present sexuality and fertility are dangerous and must be controlled.
A way to do this is to instill in women the belief that their natural bodily
functions and waste from menstruation and childbirth are “dangerous” to
others. The baby also remains in a polluted state. Neither can return to the
family until a rite of passage, of “purification” has taken place.
Fear of ritual pollution still has great power. For some time, anthropologists
have discussed what such pollution beliefs mean in relation to female
menstruation and childbirth. Regardless of which type of society and where it
is in the world, the consensus appears to be that such taboos express the
order of social relations. Within this order is gender inequality and
discrimination which need to be challenged.
There is a danger that in talking about safe motherhood as a gender issue we
mean that men are unimportant. On the contrary, it means that men should
be encouraged to join in the process of exploring the reasons for existing
beliefs and practices that may be harmful to safe motherhood, and to be
involved in finding solutions for them within the social context which is in a
process of change itself. It is important not to exclude men from any process
of bringing about such change. It was demonstrated in this study that, with a
few exception, there was a low level of awareness amongst men on any issue
affecting delivery. Most admitted knowing little about what happened to mother
or baby during delivery : “These are women’s matters. What do we know
about them ?” 15
Treating safe motherhood as a gender as well as a health
issue means that men need to become as aware as women.
15
Man in Pandusen

7.4 Supporting the TTBA programme
From this study, a picture has emerged of under-utilized, under-valued and
poorly supervised TBAs. They are seldom called, except in emergencies,
they seldom perform cord cutting and ties in normal deliveries, and they
seldom refer. Along with the fact tha they are not recognised as a traditional
service provide (bespite their title), it is hard to see their relevance in normal
home deliveries beyond providing moral support (already provided by family)
and being able to introduce mothers to the SHDK (which could happen
anyway through enhanced mass communication campaigns and via other
sources). As in anything, there are notable exceptions and much depends on
particular individuals in differenct places.
CARE has already committed itself to providing training to TBAs on behalf of
HMG. CARE’s training is of high quality. However, there are additional
responsibilities to fulfill if the TBA programme is to have long-term sustainable
effect. These are to ensure that :
• the best individuals are being trained
• those that are trained are using all their skills and knowledge (being
allowed to cut and tie the cord and not just give instructions)
• they do not lose momentum and motivation as CARE phases out
• the data they collect is good quality, and is collated and fed back into
monitoring and evaluation, and impact analysis
The Inter-Agency Group for Safe Motherhood states that “TBAs, whether
trained or untrained, are not viewed as skilled birth attendants”. This study
has demonstrated that their use and performance in Bajura even as unskilled
birth attendants still leaves much to be desired.
7.5 The potential of the SHDK
Here here is much more of a success story. This study has shown that, in
only a few years, a new aid to safe delivery is spreading and gaining
acceptance. The decision of CARE to adopt this strategy has proved justified.
CARE has had success in promoting and using the kit through TBAs, FCHVs
and other safe motherhood acivities. Of course there is also the fact that the
product itself is valued. There seems to be variability in how many people
have heard of the SHDK. Women of all ages are more aware than men, and
DAG communities tend to report less knowledge than non-DAG groups, as
well as complaining more about the cost.
The main problem with the demand for the kit is not the principle of paying for
it (people mention that they pay for jeevan jal and for paracetemol already), but
rather the high cost for many. Sustainability of supply is problematic.

Knowledge about tying the cord correctly is also still poor. Even trained TBAs,
and women who had reportedly used the SHDK, gave the wrong proceedure.
The tie towards the mother is often missed and this may be due to the
persisting belief hat this somehow “traps air, blood, gas” in the womb and will
cause a retained placenta or the abdomen to swell up. It may also be due to
a training problem or a comprehension problem in the case of the SHDK
instructions.
However, the SHDK has considerable potential to prevent death in mothers
and newborns if used correctly. It has the potential to give every member of
the household knowledge about the fundamentals of safe home delivery. It
also gives them the responsibility, rather than relying on an external service
provider.
Finally, I suggest that once a woman, together with her family .....
• knows about the SHDK
• can and does buy it
• uses it, and performs a clean, safe delivery (then waits a while for the next
one)
• has other knowledge about cleanliness, good nutrition, safe motherhood
and primary health care
• is gaining skills and confidence through non-formal education and group
involvement and activities
• is learning about women’s empowerment and gender issues
...... she is unlikely to revert back to the old birthing practice ways. All of
these are within the scope of CARE’s present remit in Bajura.

8. RECOMMENDATIONS
These are based on the findings of the study and follow on from the lessons learned
in the previous chapter.
1. Develop and implement mass education campaigns on safe motherhood
Women, and communities, need to know WHY safe motherhood is important
and what they can do about improving their own behaviour bearing in mind
their beliefs and the beliefs of those around them. To address this, mass
education campaigns using different forms of media (visual, dramatic, radio)
should be emphasised. For example, much success has been seen with the
folk songs on safe motherhood. These could be adapted for use in remoter
districts of the country like Bajura, and maybe include other themes such as
boiling blade and thread in the absence of a SHDK, and challenging the no
touching rule.
CARE could consider partnering with CEDPA to utilise their experience of
advocacy, awareness building and IEC on Safe Motherhood but tailor it to
CARE’s own field experience to develop appropriate material for Bajura. Such
campaigns should involve everyone, all family groups, including the men.
Involvement of Youth Groups is probably the best approach here in terms of
mobilisation but all generations should be involved as the exclusion of any one
group in the consultation process may result in an imbalance in level of
awareness which is likely to cause conflict. Since this study has also found
that the DAG communities have less knowledge and change behaviour less
than the non-DAG communities, special attention should be paid to
addressing them.
2. Make safe motherhood a gender as well as a health issue
The empowerment approach emphasises the need to encourage women to
actively question the reasons for their situation and to develop self-directed
initiatives to tackle their status and injustice. This is an alternative to being
passive recipients of help. Womens’ groups can be used to encourage
women to question the reasons for the “no touching” rule and the need for
physical segregation during menstruation and childbirth. Women and their
families should be encourage to talk about the way that females are
continually set apart and isolated, and left internalised with feelings of shame
and powerlessness. Connected to this :
• provoke and encourage analytical discussion of existing beliefs and
how some of these act as barriers to safe motherhood
This could entail the encouragment of all community members, (perhaps
through existing groups established by CARE Nepal or by new gender-
focused ones), to question existing beliefs that can impede safe motherhood
practice. Most importantly are the issues of ritual pollution excluding and

separating women from the normal social order at times linked to
reproduction, where the border between touching and no touching lies, why
this is necessary at all, and the consequences in terms of safe motherhood.
For example, a VHW suggested geting people to talk frankly about why they go
to India and break the touching rules, or go to Martadi or Kathmandu, and have
a baby in the house with no major calamity befalling them, and then return to
their village and rever to the old ways. A tool for initiating such discussion
could be :
• the development of social maps of “chhau”
Staff in Bajura (and elsewhere), working with community groups, could be
encouraged to compile “chhau maps” of clusters in their VDCs. Taking for
example the preceding year, symbols could be used for sano chhau and thulo
chhau, and where these took place (separate chhau ghar, chhau ghot, mujelli
kota) and if any took place in the same place. Use of SHDK, attendance by
TBA and any mortality outcomes of the deliveries could also be marked giving
graphic demonstrations of the patterns of birthing practices and factors that
tend to correspond with a death.
3. Consider undertaking further research into birthing practices in the VDCs
beyond Kolti to give a representative picture of the district
Further investigation could be obtained about the beliefs about riual pollution
and practice of delivery in animal shed ghots in the current working VDCs
east, north and south of Kolti (e.g. Bicchiya, Jukot, Wye, Rugin, Sappata),
which are influenced by geographical and cultural affinity to the districts of
Mugu, Humla and Jumla. Field-based CARE saff are already considering
this and should be encouraged.
4. Reconsider approach to TBA programme support as the potential for TBAs
to really influence safe motherhood practices on a large scale is as yet
unrealised. If support is to continue, develop a clearer strategy to strengthen
the TBAs beyond supplying training, for example by :
• checking the selection criteria of TBAs to ensure they are
suitable, interested and supported by their communities.
• improving supervision and follow-up of TBAs so that they feel
more valued and motivated
• somehow addressing the perceived problem of incentives for
TBAs, either from the family served, the community in general,
or the VDC or District funds.
• monitoring and evaluating more closely the performance of
TBAs, their equipment, what they actually utilise from their
training, and the quality of the data they collect

5. Continue to strengthen and intensify the promotion of SHDK through
existing methods (NFE, counselling, workshops) and develop new methods
• Take a more active role in improving SHDK supply at district and
VDC levels
• Pay more attention to the establishment, support and sustainability
of community revolving funds and role of CDOs and government,
and private sectors
6. Build upon considerable achievements in nutrition. Intensify efforts to
promote good quality maternal diet during pregnancy and lactation
CARE Nepal’s strategy to date of providing nutrition education through non-
formal classes, practical demonstrations, and kitchen gardening is sound, and
should continue. Nutrition education messages should continue to reinforce
the scientific basis for adopting sound nutritional beliefs and practices, and
offer people practical ways of how they can maximise nutritional consumption
within their limited resources.
Some ideas for consideration are :
• A dietary intake study (using food frequency and food recalls)
would be informative to confirm whether or not increased
awareness of good nutrition is being related into practice. Such
data is needed at baseline and as interventions proceed, to
document food practices, and to monitor any change.
• Address the imbalance between the attention to the wider problem
of protein-energy malnutrition rather than micronutrient malnutrition
alone
• Consider increasing support for distribution of iron and folate
supplements to pregnant women through the existing FCHV and
health post system but also pay aention to the women who fail to
use this system properly.
• A goitre and cretinism survey could quantify the level and extent of
the problem of iodine deficiency disorders. Through NFE and other
activities providing messages on child survival and nutrition, CARE
could actively advocate for, and promote, the use of iodised salt in
Bajura as the only sustainable way of controlling iodine deficiency,
and spread messages of the dangers of consuming non-iodised
salt. CARE could also assist HMG in the periodic disribution of
iodised oil capsules to women of reproductive age as an
emergency control measure.

• CARE should also closely monitor the food security situation in
Bajura in the coming months, and develop a contingency plan for
an emergency food programme if required. With no substantial
rainfall in the last 8 months (since September 1998), there are
already serious food shortages in Bajura which may lead to some
pockets of famine before the end of the year.
• investigation of locally appropriate methods of preserving and
storing foods could be investigated as a way of improving nutrient
consumption year round.
• as honey was mentioned as a favoured traditional food in
pregnancy and delivery, ideas for the revival of bee keeping in
collaboration with forestry activities could be considered
7. Consider developing behaviour change as well as acivity orientated OVIs
This would address the current imbalance between attention to meeting
targets on activities and achieving behavioural change. Consider developing
(through PRA and consultation with field-based staff locally) appropriate and
qualitative OVIs for evaluating behavioural change in safe motherhood
practices, in addition to the standard quantitative OVIS in existing log frames
and LRSP. Training of TBAs and FCHVs, the proportion of attended births,
and the regular convening, of mothers groups and womens groups are
currently the main indicators of programme success, and are donor-
requirements. Whilst this is acceptable as far as it goes, such an emphasis
tends to underestimate the gap between acquiring knowledge through
messages, formal or non-formal, and subsequently acting on that knowledge
and changing behaviour
8. Better define terms through the use of ethnographical baselines
9. Periodically evaluate project assumptions using anthropological methods
10. Consider applying a longer time frame to safe motherhood (and maybe
other health and nutrition work) to say 10-12 years to ensure that sustainable
behavioural change has more of a chance to develop and take hold.

CARE Nepal
P. O. Box 1661, Kathmandu
Krishna Galli, Patan, Nepal
Phones: 522800
Fax: 977-1-521202
E-Mail: care@carenepal.org
Website: http://www.carenepal.org

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