|Year : 2020 | Volume
| Issue : 3 | Page : 168-175
Exploring perceptions and experiences of community people toward chhaupadi culture in Nepal: Social-ecological approach
Prayag Raj Joshi1, Ram Krishna Maharjan2
1 PhD Scholar Tribhuwan University, Nepal
2 Central Department of Health and Population Education, Kirtipur Kathmandu, Nepal
|Date of Submission||08-Jun-2020|
|Date of Acceptance||12-Sep-2020|
|Date of Web Publication||21-Jan-2021|
Dr. Prayag Raj Joshi
Kailali Multiple Campus, Dhangadi
Source of Support: None, Conflict of Interest: None
The Chhaupadi culture contributes to the huge proportion of mother and infant mortality in Nepal. Despite a large provision in eliminating this culture in the last almost decades, the culture remains constant. The Chhaupadi Pratha after childbirth is still in practice, especially in Far-western province. Several quantitative studies described the Chhaupadi culture and some qualitative studies have also carried out on exploring the perceptions of community people regarding Chhaupadi culture, but most of the studies had taken this practice as only for monthly menstruation. To fill this gap, I aimed at exploring the perceptions of community people and their experiences related to Chhaupadi Pratha in Kailali district. A prospective qualitative study was conducted among thirty mothers and five other key informants from Godawari municipality. Data were collected through in-depth interviews, key informant interviews, and focus group discussions. Data analysis was guided by the Kenneth McLeroy's social-ecological model (SEM) including five levels of factors which influenced the maternal and child health (MCH) care practices of mothers. While mothers showed little decision-making autonomy, interpersonal factors played an important role in their use of modern health services. Besides, community and social factors as well as organizational and health system factors also shaped mothers' MCH care practices. To improve the MCH care practices of mothers, all the five levels of SEM should be taken into account while developing health programs targeting mothers.
Keywords: Chhaupadi Pratha, culture, postnatal period, social-ecological model
|How to cite this article:|
Joshi PR, Maharjan RK. Exploring perceptions and experiences of community people toward chhaupadi culture in Nepal: Social-ecological approach. J Sci Soc 2020;47:168-75
|How to cite this URL:|
Joshi PR, Maharjan RK. Exploring perceptions and experiences of community people toward chhaupadi culture in Nepal: Social-ecological approach. J Sci Soc [serial online] 2020 [cited 2021 Apr 16];47:168-75. Available from: https://www.jscisociety.com/text.asp?2020/47/3/168/307600
| Introduction|| |
Pregnancy and childbirth are the global concern as they are recognized as a risk for not only mothers but also their newborns. Moreover, these are the vital development issues for any society. It is estimated that every year about 70,000 mothers die of complications during pregnancy and childbirth. Several studies have pointed out an increased rate of adverse maternal and perinatal health conditions and outcomes associated with pregnancies, such as preterm birth, eclampsia, puerperal endometritis, systematic infections, low birth weight, perinatal death, and maternal death. However, other literature suggested that lower maternal age is not associated with adverse maternal health outcome. Notwithstanding, it is evident that timely uptake of quality maternal health services is essential in decreasing the incidence of adverse maternal health outcomes among women in all age groups.
Seclusion practice is not limited to Hindus. Belief in pollution is particularly strong among Hindus, who observe seclusion for 30–40 days. Muslims observe it for only 7 days.
The group members noted that Hindus usually build a separate temporary hut (CHOTI GHOR) for delivery and seclusion. Muslims commonly use a kitchen or the room where the DHEKI is kept.
Despite substantial progress in reducing maternal mortality in the past two decades, the use of modern health services is still low in Nepal. Existing literature indicates that women's age, level of education, place of residence, decision-making autonomy, socio-cultural practices and norms, health beliefs, and access and availability of quality health services influence the use of modern health services among mothers. Very little qualitative research has been performed on the perceptions of mothers toward MCH care practices. However, no study has been carried out on Chhaupadi period. Moreover, no qualitative study has explored the perceptions of community people toward the Chhaupadi Pratha. To fill this gap, I opted for conducting a prospective qualitative study. This study aims to explore the perceptions of community people regarding Chhaupadi Pratha in Kailali district of Nepal. Besides, I explored their delivery practice and influencing factors in using modern health services more specifically. The findings of this study will support maternal health programs and policies targeting mothers to improve their MCH care practices during Chhaupadi period.
What is culture?
There is no one agreed definition of culture yet, but a focus on culture means emphases placed on aspects such as shared norms, beliefs and expectations, spoken language, and behavioral customs. Helman opined that it is difficult to separate culture from the social, economic, and geographical context.
Chhaupadi is the burning problem in far-west province of Nepal
In general, Chhaupadi is considered women's monthly menstruation cycle, however women during childbirth also follow the Chhaupadi practice for up to 11–22 days, which is called a major Chhau (Directive Regarding Chhaupadi Elimination, 2008), whereby delivery must take place in the unhygienic shed. In this period, women and their newborns are compelled to stay in Goth for 10–12 days. The husband's role is considered an important factor, but several factors prevented husbands in Nepal from supporting their wives during pregnancy, birth, and the postpartum period, as follows: lack of knowledge about their role in childbirth, social stigma, and embarrassment and job responsibilities.
Consequently, it can lead to both maternal and infant deaths arising from excessive bleeding, septic shock, and even relatively normal complications that are not resolved due to lack of access to health care. Tuladhar stresses that the leading causes of maternal morbidity due to Chhaupadi are reproductive tract infections and uterovaginal prolapse.
Because Chhaupadi Pratha has myriad effects on the MCH, several authors situate Chhaupadi Pratha in the arena of public health, consequently recommending application of theories that can provide this scope to analyze the social and cultural issues involved in Chhaupadi Pratha, one way is through the use of the social-ecological model (SEM).
This study recognizes the intertwined relationship existing between an individual and their environment. The SEM developed out of the work of several prominent researchers, namely Urie Bronfenbrenner's Ecological Systems Theory (1979), which focused on the relationship between the individual and the environment; Kenneth McLeroy's Ecological Model of Health Behaviors (1988), which classified different levels of influence on health behavior; and Daniel Stokols' SEM of Health Promotion (1992, 2003), which identified the core assumptions which underpin the SEM.
The work of these and other researchers have been used, modified, and evolved into what is referred to as the SEM. The model addresses the complexities and interdependences between socioeconomic, cultural, political, environmental, organizational, psychological, and biological determinants of behavior. This theory claims that the individual behavior is influenced by several factors at different levels. Similarly, it emphasizes that the individuals are responsible for instituting and maintaining lifestyle to reduce risk and improve health. . There are several versions of the SEM, which use slightly different classification of these levels. For this study, I am using five levels according to Sallis and Owen, (Sallis and Owen, 2002 as cited in Chimphamba Gombachika, 2012) of McLeroy's SEM's first level: individual, which includes the characteristics that influence behavior such as knowledge, attitudes, skills, and beliefs; second level: interpersonal processes, which provide social identity and role definition such as partner, friends, and family; third level: organizational, which includes rules, policies, and formal and informal structures; fourth level: community with established norms and values, standards, and social networks; and the fifth level: societal, which includes cultural context and national policies on health. A major strength of the social-ecological approach to health in this study is that it was possible to offer strategies of behavioral change and environmental enhancement.
Multi-level analyses among individual, interpersonal, organizational, community, societal, and related intervention strategies were also possible as shown by Reifsnider et al. At the same time, however, SEM reflects certain practical limitations. The incorporation of multi-level analyses proved to be cumbersome and complex.
| Methods|| |
This was a prospective qualitative study in which data were collected from mothers who had baby aged below 2 years. Multiple data sources were used to triangulate and validate the findings. We conducted key informant interviews (KIIs) with different stakeholders to validate the findings from mothers with in-depth interviews (IDIs).
This study was conducted in Kailali district of Nepal. Kailali is the Terai region where most of the migrated people are residing with a common culture. We purposively selected mothers residing in Godawari municipality. Socio-economic conditions, cultural practices and beliefs, and access to maternal health services are quite similar for the people living in this region. Lots of governmental, nongovernmental organizations (NGOs), and private health institutions are providing health services in this region.
Qualitative data were collected from a wide range of respondents. In addition to mothers having children aged below 2 years, the main study population, we collected data from community health workers, community people, family members of mothers (mothers-in-law and husbands), and representatives from the government, NGOs, and health providers. [Table 1] shows a list of study participants and data collection methods.
|Table 1: Factors that help in continuing Chhaupadi Pratha based on social-ecological model|
Click here to view
We collected data purposively from different types of respondents to obtain rich data. IDIs were conducted with mothers. During the interview, they were asked about their knowledge, perception practices, and experiences related to maternal health-care services during Chhaupadi period and their intended delivery places and methods. The female students of bachelor first-year majoring health education collected data from the mothers. Research assistants were trained to conduct interviews in a way that biases such as dominant respondent bias and shyness bias were reduced. KIIs were conducted with representatives of the government, NGOs, and hospital personnel, who had been working in the health sector. Finally, three focus group discussions (FGDs) were conducted with community health workers, members of political parties, and mothers-in-law to validate the data gathered via IDIs and KIIs as well as to explore common practices and barriers to the use of maternal health services. Only the interview guides were pretested in Dhangadhi sub-metropolitan city and adapted. All topic guides were developed in English and translated into Doteli, before pretesting[Table 2] Source: Filed survey,2020.
Data analysis and theoretical framework
Using the SEM as an analytical lens, this study explores the perceptions of mothers regarding MCH care practices during Chhaupadi period at the individual, interpersonal, organizational, community, and societal levels. The data were analyzed manually using the SEM as an initial coding guide. The SEM is a theory-based framework which considers the complex interplay of multiple levels of a social system and interactions between individuals and the environment within this system. The SEM thus adequately facilitated the exploration of mothers' experiences, integrating their intrapersonal, partner-related, family, community, and socio-cultural contexts to produce one behavioral outcome regarding Chhaupadi culture. Guided by the objectives of the study and the SEM, an initial coding framework was generated after reading a subset of the transcripts. Newly emerging text segments or codes in subsequent transcripts were inductively added to the framework to build our model of factors influencing maternal healthcare-seeking behavior. When new codes or themes were added to the framework, all data were re-scrutinized to assess their relevance. The data from IDIs, KIIs, and FGDs were scrutinized several times to obtain a sense of the whole. Researchers with different backgrounds provided input to the analysis to increase its validity.
| Results|| |
Thirty-five IDIs were conducted in total with mothers. Among the 35 mothers, one experienced a neonatal death.
Characteristics of the respondents and use of maternal health services
Among 25 mothers, 11 delivered at a health facility, whereas 14 delivered at home. Of those home deliveries, four were assisted by nontrained birth attendants. Among those who delivered in hospitals, seven had cesarean sections. Fourteen mothers and their newborn babies did not receive any postnatal care (PNC). PNC information was collected from 28 mothers. Among them, nine did not know about the institutional delivery. The rest of the respondents who knew about institutional delivery seemed to know this information from their husbands and friends. Among those who delivered in the hospital, about 60' went to a private hospital and the rest of mothers went to a government hospital.
Social-ecological approach to explore the perceptions of respondents
Emerging factors were grouped along with the SEM layers, categorizing the study findings into individual-, interpersonal- and family-, community- and social-, and organizational-, and health system-level factors, influencing the usage of modern health services.
The 25 mothers who took part in FGD were below 42 years of age. Only two mothers had completed higher than the secondary education and 15 of them had a primary or lower level of education. The majority of the mothers had limited knowledge of MCH care (Natal Care and PNC). We observed that the mothers' perceived need for health care during pregnancy and childbirth influenced their use of skilled maternal health services. Most of the mothers perceived pregnancy as a normal phenomenon and do not think about health check-ups unless they are suffering from any complications.
I didn't go anywhere because I didn't have any problem (a mother, IDI).
Almost all the mothers first tried to give birth at home and when it failed, they were taken to the nearest hospital for delivery. Mothers' intention was to deliver at home because of the perceived threat of getting operated at the hospital and its potential consequences. A mother, who delivered her child at home, mentioned the following:
There are a lot of problems if we go to the hospital; if they operate there is a problem in moving. There is a problem in eating, for three to four months we can't do any heavy work (a mother, IDI).
Three mothers mentioned that they felt shy going to the hospital as there were many people at the hospital. They felt uncomfortable at the thought of being seen by male doctors in the hospital.
It will be better if it happens at home. If we go to hospital men will be there. It is better if nurses are there to do it. I heard male doctor will be in hospital it makes me feeling shy (a mother, IDI).
There are a lot of people at the medical, I will be ashamed. The doctors see my private part. A lot of people see my body. That's why I didn't feel like going to the medical. That's why I want to deliver at home (a mother, IDI).
The majority of the mothers expected to have family members around them during the time of delivery. Therefore, they preferred home delivery to have direct support from the family members. Mothers had little decision-making autonomy regarding maternal health care because they depended on the decisions of their husbands or parents-in-law to seek maternal health care. When we asked about the restrictions during the postnatal period, one of the mothers replied:
We have a Shed next to our home. Any mother who is in this situation can live there. So, I didn't ask anyone about a place to live. I lived in Chhaupadi Goth till Nwaran of the baby. This is our tradition to live in the shed during this period for the prosperity of our family (a mother, IDI).
The same question was asked to another mother, she replied that:
We have only one home, where all the male members of the family like my parents in law, brothers in law live together. So we can't stay there. It makes me ashamed. I asked my parents in law for making a separate sanitary hut for this provision, but they had no money to prepare on time.
Interpersonal- and family-level factors
Some decisions were made by the family tradition. In most of the cases, family members demanded that pregnant women should deliver at home with the help of relatives and older women who had experience in childbirth. When women failed to give birth at home, she was taken to the nearby hospital.
One of the mothers said:
During my last delivery, I felt difficulty. My pain started at midnight. I tried myself but couldn't be free then my husband called my mother in law then she tried to massage but the baby was not coming out. I tried a lot till morning. At last, they took me to the hospital (a mother, IDI).
A staff nurse who had been working at the hospital confirmed such experiences in a KII:
I would say home delivery is happening as a part of their tradition in the family. They do not prefer to go to a doctor as they have birth attendance and they prefer to welcome this baby within their environment.
Decisions regarding Chhaupadi practice during the postnatal period were influenced by different family members especially husband and mothers-in-law. One of the mothers mentioned:
My mother in law said it's our culture to go Chhaupadi Goth for at least 12 days. You can see all women who are doing so without questioning. If we break the rule of our Kuldeuta, what would be in our home? When I felt uneasy in Shed, I requested to my husband for providing some additional materials, he said that I have no authority to cancel my parent's decision, then I couldn't ask to my parents (a mother, IDI).
This was confirmed by the KII. We asked a political leader.
We did not know this case. We used to take Chhaupadi Pratha for only monthly menstruation. We tried to eliminate that tradition through awareness campaigns. This is our culture to live in a separate hut for 12 days. Now, we will try to manage it (political leader, KII).
Mothers-in-law are the decision makers and caregiver, and they believe that the postnatal period is the impure period that makes the home polluted. Lack of awareness is the main cause of this. Our new mothers have no decision autonomy. Hence, it can be said that thek persons also were not aware of the restriction practices and their traditional perceptions of maternal health.
We used to live in Shed for 22 days. But, now we have reduced the restriction period. We do not show our newborn to others. There may be evil spirits also. And you can see our homes. They are three storeys. In upstairs there is the THAN (place) of Kuldeuta and cows are downstairs and all the male members of the family in midst airs. How can we live in the same home? (a mother-in-law, KII).
It shows that the mothers-in-law have the strongest influence in the family in Kailali district. The same questions were asked to a health professional who has been working in this area for 2 years.
They still have a negative attitude toward health professionals. They come here only after being severed. They believe more on TBAs than us. Most of the mothers in law help mothers during and after delivery. So, most of the mothers depend on their mothers in law (a health professional, KII).
Community- and social-level factors
We included the role of neighbors and community health workers, poverty-related factors, socio-cultural norms, traditional practices, religious and spiritual beliefs under the category of community or social factors influencing mothers' MCH care practices.
Most of the mothers said that they accepted Chhaupadi Pratha as shown by the following quote:
Living in Chhaupadi GOTH is our culture. Nobody can prevent it. If they stay at home, I have to leave this home forever. I am a PUJARI of our KULDEUTA So, I am not allowed to involving in birth and death ceremonies even my wife, ploughing, eat the bread of Millet, Every family in this community which has some new cases like birth and death, I have to do all the household activities for me. Nobody can touch my utensils except daughters but daughters are not allowed to wash utensils, wash clothes, carrying fertilizer to the field. You can see, I am a very poor person. I have no income source. I can plough in my field, but our KULDEUTA does not permit me. So I hired a person for ploughing. I have to pay money from selling these grains.
I asked a political leader for confirmation.
Yes, this is our tradition. We had tried to minimize this tradition. But nobody is ready to eliminate this PRTAHA. He is the PUJARI of our KULDEUTA. He can't quit this behaviour in his life (a political leader, KII).
Poverty also prevented some women from going to a health facility for delivery. Although women in the Terai district receive Rs. 500 for each delivery at a health facility, additional fees for transport, food, and living arrangements for an accompanying member can increase the total cost to more than NRP 2500. If families cannot cover these extra costs themselves, women deliver their babies at home. Sometimes, district health office delays payment and mothers do not receive the funds instantly and the poorest families could not afford to visit a health facility. A service provider from Kailali noted:
Sometime it may be a delay, at that time we provide the delivery incentive to the mother only 3–4 months after the delivery.
Socio-cultural norms played a very important role in home-based delivery and seeking care from a religious scholar, instead of going to seek services from skilled health-care providers during pregnancy and postpartum. Almost all were Hindus.
My husband is the only son of my parent's in law. My parent's in law are above 60 in age and they are illiterate. My husband was in India. When I was suffered from pain, my neighboring brother in law wanted to help me to take hospital but my parents in law did not permit. They are religious people. They said when a female patient goes to the hospital, there are male doctors. That's why it is better to deliver at home and I gave birth at home (a mother, IDI).
A community health worker from Godawari explained during an IDI that:
There are some rigid Brahmin families (followers of Shaileshwari) families, who said,
We are the followers of Goddess Shaileshwari, we take our women as the Devi then why would some other men touch our wives? That's why they don't take them to the health care centre.
Cultural and spiritual beliefs inspired the use of traditional and spiritual healers. Health problems of pregnant mothers and newborns were often considered as the act of evil spirits. Such beliefs and myths perceived by mothers and their family members inspired them to seek care from traditional and spiritual healers.
Because my first baby died so everyone said there was an evil spirit on me. Then we got house purified (Graha Shanti). I and the baby got Gahut (Cow urine) on our neck.
That's all (a mother, IDI).
I asked the mothers about not living in the home during this period, one of the mothers replied;
Once, I was crossing my way nearby home, I unknowingly touched my father in law during that period. Everybody scolded me. Then, community people advised us to conduct a Rudri Shanti Puja at home. Then we conducted for being from that sin. After doing so, I never tried to go near to them (a mother, IDI).
Organizational- and health system-level factors
Availability, accessibility (i.e., distance, cost), and quality of maternal health services were grouped under organizational- and health systems-level factors. Organizational- and health systems-level factors also played an important role in the use of maternal health services by mothers.
In terms of government health facility, the Government of Nepal (GoN) established birthing centers.
However, it was found that often birthing centers were not equipped with basic instruments. One of the community health workers during KII said:
We have no plenty of materials and sufficient manpower. You can see here, I am alone now among six staffs they all are in home leave. We complained to the district hospital. If we can't provide the service due to the lack of manpower and facilities, they don't want to come here further and they feel so irritated toward us (a health worker, KII).
Availability of health centers and accessibility and lack of attention by the health-care providers were also mentioned as the reasons for not seeking NC, as illustrated by the following quote from a social worker of that community in a KII:
Birthing care centres are very few and too far. These are functional for only two days a month. If there is one more clinic day in a month, that will be better. If we combine all these, then good care will be ensured (a social worker, KII).
The mothers also mentioned the low quality of the service provided by public facilities as the major reason for not choosing the public hospital for childbirth. A mother said that they preferred private hospitals because of its nature of fast service delivery although it was costly compared to the cost of the services provided by the public hospitals. Along with this question, I asked about government policy about Chhuapadi, she mentioned that:
We do not know the government policy. Our family and community policy are dominant than others. Nobody will be ready to quit this tradition. Our political leaders blame this tradition but they are practising in their home. Who will be responsible if something happens in our family? (a mother, IDI).
I had asked a political leader about government policy regarding the elimination of Chhaupadi culture.
We usually take Chhaupadi as the menstruating women and this policy is also for menstruation. We have neglected this pratha. We destroyed the many Chhaupadi Goth, we prevented the women from living in Chhaupadi Goth during menstruation period. But we didn't do anything for postnatal mothers (a political leader, KII).
| Discussion|| |
This study showed that several interlinked factors influenced MCH care practice among mothers in Nepal. In terms of individual-level factors, mothers' knowledge and perception about delivery care and Chhaupadi practice shaped the use of MCH care practice. Almost all the mothers expressed their wish to deliver at home because of their perception about the importance of maternal health care, the expectation of getting family support while home delivery, being shy to be seen by male health-care providers at the hospital, and wanted to stay in Chhuapadi shed after birth. They go into seclusion in the period immediately after birth for two reasons: first, because they are considered to be particularly vulnerable to the attention of evil spirits at that time, and second because they are considered impure. However, many mothers delivered at the hospital in the event of severe complications and failures of the attempt of home delivery mostly by the nontrained birth attendants tried to eliminate this Pratha. Marriage in young age is also in practice here and being young, with low level of education, and with unemployment, they are fully dependent on others. This study shows that mothers often had very little decision-making autonomy. This was influenced by several intertwined factors. Hence, they are restricted in deciding their health-care practices. Furthermore, because of low levels of education, they had limited knowledge about reproductive health problems, a finding which has also been corroborated in other studies. Besides, they often hesitated to communicate with husbands and other family members because of their culturally grounded gender role, leading to a limited level of autonomy.
Conventionally, women give birth at home without any problem, which compels mothers to rely on past events and feel safe while giving birth within the family environment. Thus, a family tradition emerged as the strongest influencing factor. Husbands and mothers-in-law decide the MCH care practices by limiting the mothers' decision-making autonomy. Despite this fact, it is also a common practice in the Far Western province that because of shyness with parents no women give birth in their mother's home. Mothers feel shy to go to their parent's home in this period. In that case, mothers' own parents' knowledge and perception influence MCH care practice.
Separation from men is ensured by the feelings of shame that a woman experiences at this time. These feelings begin during pregnancy but are intensified during and after delivery.
Under the community- and social-level factors, religious beliefs emerged strongly as influencing factors. Most of the families were from rigid Brahmin. Hence, they hesitate to send their wives to the hospital alone. Therefore, some women whose husbands were not present at home were compelled to deliver at home.
Placement of Chhaupadi in a separate room after childbirth for up to 12 days after delivery is among such cultural practices. Some beliefs such as fear of evil spirits and their effects on the mothers are grounded in cultural beliefs rooted in the rural society. New mothers are not allowed to do normal housework, and their movements are restricted during their stay in the Chhaupadi shed. Some of them said that such restrictions are not always followed, especially by poorer women; only the women who are better off can afford to follow them strictly.
The lower level of education among rural women may contribute to the major reason for maintaining such kind of beliefs and practices.
All the limitations on mobility, whether due to fear or shame, clearly reflect the lack of autonomy of rural Nepalese women and have important implications for their access to medical services whether for routine care or in the case of illness. The restrictions are most stringent during and after childbirth, at the time when women may most need access to medical care.
The contribution of community health workers in improving MCH care was important in the study areas, which positively influenced some mothers to use modern health services. Despite the presence of health workers, strong family tradition and individual and family members' perception of maternal health care still contributed in limiting mothers' use of modern health-care services. The quality of health-care services, the efficiency of health centers, and the attitudes of the health personnel were mentioned as barriers to using maternal health care. According to Yaya and Ghose, the main challenges for promoting maternal health care utilization in resource-limited settings are surrounding those of accessibility and affordability barriers stemming from various infrastructural, skilled human resources, technological and financial issues at the health systems level and poor health literacy, self-efficacy, and behavioral factors at the individual level. Evidence suggests that access to quality maternal health care has significant implications on quality of life and well-being among mothers, which serve as the prerequisite of women's socio-economic empowerment and promoting gender equality.
The influences of Western medical practices, urbanization, and education have persuaded many middle- and upper-class women to seek medical intervention and have a doctor attend their childbirth in a hospital. However, women from the working class, a low socioeconomic background, are tradition bound. Most of these women prefer home delivery attended by a local birth attendant who is an experienced village woman because of the former's familiarity with local customs and traditional practices, the practices often criticized by trained professionals.
Thus, the GoN should take steps to strengthen the monitoring system to track the performance of the birthing centers and to make all the community health institutions functional.
| Conclusions|| |
This study revealed that all the four levels of factors in the SEM shaped the MCH care practices of mothers in Kailali district, with influences also cutting across the levels as shown for low decision-making autonomy for instance. Because young mothers have less decision-making autonomy and knowledge about MCH, interpersonal- and family-level factors such as husbands and mothers-in-law played important roles in their utilization of modern health services. Our data show that ensuring the availability of quality maternal health services in government facilities is important in building trust among young rural women. To promote the use of modern health services, interventions targeting all the four levels of the SEM are needed, calling for different types of strategies addressing the different levels. However, interpersonal- and family-level factors should be given special attention when targeting mothers, as family members are the ultimate decision makers for them and likely the most influential in the use of skilled maternal health services.
Limitation of the study
This is usually the case with qualitative data, which serve to explore issues in a given context and contribute to deeper insights into specific phenomena. However, we believe that the information gathered from a diverse group of respondents was rich enough to present a realistic scenario of MCH care practices of mothers.
Because of cultural issues and participants' illiteracy levels, verbal consents were obtained with the presence of their legal guardians. Before conducting each FGD, we explained the nature of the study, its rationale, and the extent of involvement expected from the participants. A witness read the informed consent form to illiterate individuals and those who consented to participate placed their thumbprint on the form, which was signed by the witness. To establish trustworthiness, we adopted approaches discussed by Krefting. Confidentiality was strictly maintained: only the researchers had access to the data and no personally identifying information was kept that could personally identify respondents after the research had been completed.
I acknowledge all members of our family.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]