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Gender Inequalities and Childbearing: a Qualitative Study of Two Maternity Units in Nepal Lesley Milne Bournemouth University, UK, [email protected]

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Gender Inequalities and Childbearing: a Qualitative Study of Two Maternity Units in Nepal Lesley Milne Bournemouth University, UK, Lmilne@Bournemouth.Ac.Uk View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by eCommons@AKU Journal of Asian Midwives (JAM) Volume 5 | Issue 1 Article 6-2018 Gender Inequalities and Childbearing: A Qualitative study of Two Maternity Units in Nepal Lesley Milne Bournemouth University, UK, [email protected] Jillian C M Ireland Ms Poole Foundation NHS Trust, Poole, UK, [email protected] Edwin van Teijlingen Tribhuvan University, Nepal, [email protected] Vanora Hundley Bournemouth University, UK, [email protected] Padam P. Simkhada Public Health Institute, Liverpool John Moores University, UK, [email protected] Follow this and additional works at: https://ecommons.aku.edu/jam Part of the Nursing Midwifery Commons Recommended Citation Milne, L, Ireland, J C, Teijlingen, E, Hundley, V, & Simkhada, P P. Gender Inequalities and Childbearing: A Qualitative study of Two Maternity Units in Nepal. Journal of Asian Midwives. 2018;5(1):13–30. Journal of Asian Midwives (JAM), Vol. 5, Iss. 1 [2018] Gender Inequalities and Childbearing: A Qualitative study of Two Maternity Units in Nepal 1Lesley Milne, 2Jillian Ireland, 3-4Edwin van Teijlingen*, 5Vanora Hundley, 4+6Padam P. Simkhada 1. Senior Lecturer Midwifery, Faculty of Health & Social Sciences, Bournemouth University, UK. Email: [email protected] 2. Professional Midwifery Advocate, Poole Foundation NHS Trust, Poole, UK. Email: [email protected] 3. Professor, Centre for Midwifery, Maternal & Perinatal Health, Faculty of Health & Social Sciences, Bournemouth University, UK. Email: [email protected] 4. Visiting Professor, Manmohan Memorial Institute of Health Sciences, Kathmandu, Nepal. 5. Professor of Midwifery, Centre for Midwifery, Maternal & Perinatal Health, Faculty of Health & Social Sciences, Bournemouth University, UK. Email: [email protected] 6. Professor, Public Health Institute, Liverpool John Moores University, Liverpool, UK. Email: [email protected] *Corresponding author: Edwin van Teijlingen Abstract The role and status of women in South Asian countries like Nepal are widely recognised to be lower than that of men. This gender inequality can be found throughout all levels of society. Our study is about the influence of gender on pregnancy and childbirth, which are very much in the female domain in South Asia, both at home and in health facilities. A mixed-method, qualitative research study was undertaken in two birthing facilities in Kathmandu Valley to examine barriers to women accessing these services from the perspective of hospital staff. Thematic analysis identified seven subthemes related to gender, namely: (1) support from family, autonomy & decision making; (2) women’s workload; (3) finances; (4) women wanting female doctor; (5) consent; (6) delivery room; and (7) preference for male offspring. Overall, gender-based roles negatively impacted many stages Published by eCommons@AKU, 2018 13 Journal of Asian Midwives (JAM), Vol. 5, Iss. 1 [2018] of the mother’s childbirth journey. Some staff recognised gender roles as a barrier to women accessing services but did not recognize themselves or their practices as a potential barrier. Gender issues identified at both birthing facilities generally reflect those of Nepali society as a whole. Raising awareness among maternity-care workers about gender issues and what they can do about it in personal interaction and how they reflect can on it would be the first step to improving the experiences of women of childbearing age. Keywords: Skilled birth attendant, Health personnel, Barriers, Access, Gender, Childbirth, Maternity, South Asia Introduction The experience of pregnancy and childbirth is always set within a particular cultural context. Females are disadvantaged in many cultures from the time of their birth. In South Asia, women’s childbearing journeys depend upon many socio-cultural factors including wealth, access to education, women’s status in society and within her family, beliefs, customs, traditions and taboos.1-4 These factors can have an influence on Nepali women’s abilities to access maternity care locally. The same factors also impact the mostly female maternity care workforce. It is not just about the role and place of women in Nepalese society, it is also about attitudes towards and expectations of women. Many authors writing about maternity services in Nepal refer to its patriarchal and traditional value systems and practices that discriminate against women.4-5 Sociologists use the concept of patriarchy to explain the unequal power relations between the genders whereby women are systematically disadvantaged and discriminated against in (all levels of) society. This unequal relationship exists in both high- income countries, such as the UK (United Kingdom) or the Netherlands, as well as in low- income countries such as Nepal or Pakistan.6 One of the differences between high- and low- income countries is that the gender inequality in more traditional societies is perhaps more obvious. In Nepal a woman generally leaves her family home on marrying and lives within the extended family of her husband. In that household there is typically a division of labour based on gender and social position in the family. Her mother-in-law has power over the younger https://ecommons.aku.edu/jam/vol5/iss1/3 14 Journal of Asian Midwives (JAM), Vol. 5, Iss. 1 [2018] women in the household and has control over the movements and decisions regarding daughters-in-law.7-8 This will include a wide range of decisions such as what she eats, how heavy her workload is in and around the house, whether or not her children attend school and whether or not she is permitted to access antenatal care. So a newly married women leaves the home where gender has been the biggest determining factor in her life to a new home in which another layer of power – that of the mother-in-law is added to her life. This affects a woman’s chance of having a safe birth. For example, a woman in Nepal is significantly less likely to access a facility for birth if her husband has other wives (OR: 0.17; 95% CI: 0.05– 0.63).4 Having previously explored staff perceptions of barriers to facility birth in Nepal,9 in this paper we specifically explore how gender is perceived by staff as limiting access to birthing facilities and skilled intrapartum care. Methods This mixed-methods study10 comprised semi-structured interviews and non- participant observations. The primary aim of this qualitative research was to explore staff perspectives about barriers to women accessing a facility birth in Nepal, and in this paper we focus largely on gender roles and inequality. Semi-structured interviews11,p.116 were conducted with staff working in two small non- governmental hospitals both offering facility based birth to local poor women within their respective catchment areas. Non-participant observation was conducted by the first author in both of these hospitals.9 A total of twenty participants (P), both male and female, were interviewed, ten at each hospital site. SBAs (skilled birth attendants) included: three auxiliary nurse midwives, two doctors, five staff nurses and four health assistants as well as four support staff such as laboratory technicians and receptionists. Data collection took place over a period of one month at the two hospital sites. Both hospital sites are located in Kathmandu Valley; one is an urban hospital (UH) and the other a semi-urban hospital (SUH), these abbreviations are used as identifiers in the quotes below. Written consent was obtained from each participant and each participant was interviewed separately by the first author in English or through a Nepali interpreter. All interviews were audio taped and transcribed verbatim. Nepali recordings were translated prior to transcribing and four were chosen at random to be translated twice by two independent translators to test the reliability of translation. Twenty five hours of non-participant Published by eCommons@AKU, 2018 15 Journal of Asian Midwives (JAM), Vol. 5, Iss. 1 [2018] observation was undertaken by the first author at each site. The interview and observation data were analysed using thematic analysis.11-12 The Nepal Health Research Council and Bournemouth University’s ethics committees granted ethical approval. Results The theme of gender inequality has been divided into subthemes which are exemplified using extracts from interviews and pertinent observations. These seven subthemes are: (1) support from family, autonomy & decision making; (2) women’s workload (women’s completing roles, reproduction verses productive); (3) finance; (4) women wanting female doctor; (5) consent; (6) delivery room; and (7) preference for male offspring. 1. Support from family, autonomy and decision making Participants said that a woman’s decision to stay at home to birth her baby or to attend the birthing unit for delivery was predominantly influenced by either the woman’s mother-in- law or the woman’s husband. Participants made comments indicating it was not the pregnant woman herself who made such decisions: “Most of the women do the home delivery as their mother-in-law prefer home delivery practice.” (SUH P3). A hospital secretary noted that: “There are many FCHVs (Female Community Health Volunteers) working in [name removed] community and mothers-in-law of pregnant women [are] influenced [by]…them. Then, mothers-in-law…also encouraged pregnant women [daughter-in- law] to go to hospital for delivery. Some women also get help from their husband.” (SUH P8). To a lesser degree, participants from both hospitals also suggested that sometimes either the woman herself or other senior family members, such as the woman’s own mother or father or the woman’s sisters or neighbours, influenced this decision. A medical officer from the rural unit stated: https://ecommons.aku.edu/jam/vol5/iss1/3 16 Journal of Asian Midwives (JAM), Vol. 5, Iss. 1 [2018] “Sometimes they [the women themselves] also decide and sometimes their seniors and their neighbours suggested women to come to hospital.” (UH P3).
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