Constructed on the biggest faultlines in the world, Nepal is one of the world’s poorest countries. It is landlocked, between India and China, and mountainous, situated between the Himalayas and the plain of the Ganges river. The effects of the fault are evident in the changing contours of Nepal’s biggest tourist attraction: the 1,400 mile Himalayan mountain range is pushed up by about a centimeter each year by the constant collision of the India and Eurasia plates. Today, Nepal’s 27 million residents have a per capita GDP of under US$1.
Despite political instability in the last two decades, Nepal achieved remarkable progress in reproductive health care, including family planning. Total fertility rates decreased from 6.4 to 3.4 between 1995 and 2005. Contraceptive prevalence increased twenty percentage points in the past twenty years. There are a number of factors that likely contributed to this success. First, family planning was well integrated into a national immunization program, meaning that every woman who seeks vaccinations for her young child also received counseling and access to contraceptive options. Second, the legalization and rollout of safe abortion services in 2002 contributed to a reduction in serious abortion-related mortality. Third, a massive social marketing campaign on smaller family size was distributed through radio and print publications.
Still, a quarter of women still have an unmet need for contraceptives and corruption abounds. For example, there was a national stock-out of the highly effective contraceptive implant this year, simply because the Minister of Health didn’t approve of the supplier that the procurement committee had selected, and thus prohibited the importation. Nepal has also seen a slip in family planning use in the past decade. Indeed, the most recent Nepal Demographic Health Survey showed a notable decline in the contraceptive prevalence rate between 2006 and 2011. Theories explaining this trend point to the high proportion of spousal separation, an increased use of traditional methods, and the inherent challenge of continually delivering products to very remote areas and marginalized populations. And, that was all before the earthquakes.
Nepal had made immense progress in strengthening its reproductive health system in the past several decades, but the earthquakes decimated this foundation. What happens next?
It is well established that access to reproductive health care has broad public health, political, economic, and social implications that span far beyond individual level impact. Research has shown that family planning is one of the most cost-effective ways to reduce maternal mortality, and that declines in fertility through family planning are linked with accelerated economic growth and poverty reduction. Tremendous power accompanies the ability to plan one’s family size, and access to education and employment follow closely behind. However, our goal in this photo-essay is to not to rattle off statistics or even to make a case for investing in family planning.
We are students of business and public health at the University of California-Berkeley and Dartmouth College. In June of 2015 we went to post-earthquake Nepal to speak with women, frontline health volunteers, doctors, nurses, administrators, and government officials in order to explore the barriers and the goals in universalizing access to reproductive health care. We document their stories here. Our goal is to act as conduit for the narratives, values, and perspectives of the individuals and families seeking health care in Nepal, and the everyday heroes that are currently re-building the Nepali health system. These are their stories of resilience and reproductive health in Nepal.
The 7.8 magnitude earthquake of April 25, 2015 was described as “strong and shallow.” It swam up from beneath the earth’s surface and unleashed a shock wave as powerful as the explosion of more than 20 thermonuclear weapons. Those that experienced the quake in Kathmandu said that it went on for six full minutes. The earth rocked, flower pots fell off balconies, and the walls of buildings rippled as if they were one giant heat wave. This earthquake was no surprise; the last deadly quake had been more than a century earlier, in 1904, and scientists and the government had been anticipating the next “big one” for decades. In fact, exactly one month before the earthquake hit, the World Food Program and the Nepali government had finally opened an emergency preparedness cargo area at the Tribhuvan International airport. The country was immediately prepared to receive tons of relief materials, though its capacity to deliver aid to the people in need was far less established.
“Only 80% of female community health volunteers have resumed their duties. Many of female community health volunteers are living outside of their home in tents, too afraid to go back. Women in our district have experienced an interruption of family planning services since the earthquake.”
- Manish, District Health Official, Dhading District
The geography and seasonal changes of Nepal have always presented enormous challenges for the country’s national health system. Roads are often completely washed out during the three-month summer monsoon season, so many communities are entirely cut off during months of the year. Even before the earthquake, these communities would choose to travel overland to China for basic medical supplies, instead of making the multi-day trek to the nearest Nepali health center offering free care.
After the earthquake, the Ministry of Health and partner relief organizations rushed to deliver three-month supplies of essential medicines to the most remote villages before the rains hit. Health center staff across the country salvaged all the medical supplies they could from damaged health facilities. They moved these pills, vaccines, sutures, and bandages to makeshift structures, or sometimes their own homes, to provide emergency care.
Now, humanitarian actors and government health officials struggle with whether they should implement temporary solutions to meet immediate needs, or implement higher-quality, permanent solutions that more sustainably support the people of Nepal. They ask themselves whether they should accept donated canvas tents sturdy enough to withstand the impending winds and ground-shattering monsoons, even knowing that this tent may only last for one season. They question when the right time is to rebuild, knowing that there have been 474 aftershocks stronger than 4.3 magnitude since the original earthquake. Meanwhile, the medical providers pick up where they left off.
“The earthquake hit on a Saturday, and on Sunday I was able to salvage the essential medical supplies, including family planning supplies. We just resumed. Now, I am providing services 24 hours a day from my home because of the turmoil. While I’m cooking dinner, or when I’m caring for my infant, women come to me and I provide services. The most common time that women come to me seeking family planning is at night, when they finish farm work. During the recurrent after shocks we always run outside to open spaces. We are still afraid, but we have not stopped providing services.”
- Amra, age 32, mother of one, Auxiliary Nurse Midwife, Sankosh Village
“Some families in our village must walk three and a half hours by foot to get to this health facility. Our staff must walk two hours to bring clean water here, which is a real danger to safe motherhood.
The biggest barrier to women accessing family planning here is that people are just unaware. Some people think they should not use family planning because they are against their religion. Other parents have enough children but don’t know about family planning, so when they conceive they want to abort. Many think that the earthquake damaged their pregnancy. I think lack of health education and awareness is the main problem. We should use community meetings to inform people about family planning methods and proper maternal health care, but individual conversation is also important – I’ve had the most success in connecting with women when I go door-to-door to talk to them. I believe that if you could increase awareness of family planning, and stop myths before they spread, it would increase usage.”
- Navina, age 36, mother of one, Auxiliary Nurse Midwife, Dhading District
“There are rumors in this place that the earthquake damages the baby [in utero] and it’s hard to deny it because even the animals – the goats and the buffalos – are losing their babies.”
- Chitra, age 73, mother of four, grandmother of twelve
Every single car that we passed on the mountain roads in Nepal was an aid vehicle—PLAN International, Oxfam, UN, WHO—and as we careened up the hairpin turns until we could see the clouds reflected on the hills below, we could not help but notice the shellshocked expression on everyone’s faces. Roads are now half their normal width because the rubble has fallen alongside the edges, or because landslides have taken out the right lanes. Now, valleys across Nepal are dotted with candy colored tent villages, as entire villages have moved from the upperlands to the district centers to set up camp.
“We were having lunch when we felt the earthquake, and then everyone started shouting, like “Earthquake is coming!” so everyone ran out of the house. Just as we came out the house we realized that my wife and baby [these two] got trapped inside. With the grace of God, she grabbed the baby and somehow got out. Even she doesn’t remember how she managed to escape. After she got it, the house was leveled completely. We were 10 members at home: Brothers, sisters, in laws, parents, and children.
After the earthquake we walked here with nothing. We had nothing to take: No house, no clothes. There were no roads. Staying in the village would have been impossible, so we came here to seek help from the government. The government did give us 15 kilograms of rice per house. The tarps we live in were provided by NGOs, and we bought the bamboo to hold them up.
For about a week after the earthquake, we didn’t feel like eating anything. Not because we weren’t hungry, we just didn’t have any desire to eat. Though our immediate family is okay, most of our neighbors and relatives are all dead. From our village, 14 of our relatives have died. So for days we were in grief and didn’t feel like eating. We cried so much in the weeks following the earthquake but we cannot cry forever. We don’t really feel like smiling, but we’ve cried enough from this disaster so now we must smile, because we don’t know how long this will be.
We have five family members living in this tent: My brother and his wife, me and my wife, and our child. There are total of 100 tents in this village, and everybody is in the same situation. Even this land where we are staying here right now is not our land—it is owned by somebody else. If the landlord came and asked us to move, I would not be sure where to go. We can go to the district hospital for health services, but we are not from here so we feel like outsiders when we enter.”
- Amrit, age 42, father of one
In addition to moving entire villages into valleys, hundreds of pregnant women have travelled from the “upper areas” of Nepal to the nearest district hospital to give birth after the earthquake. Following birth, women may stay up to three months in a UNICEF postpartum tent outside of the district hospital. The Government of Nepal provides bags of maize each week, and families may come visit daily. It can be challenging to plan for the future of the family when the future is so unclear.
“This is my second child. More than this would be a challenge with the economics and with the health. If I don’t use a family planning method I’ll have another baby, and I don’t want that. Most women choose a permanent method for that reason. I will too.”
- Jana, mother of two: 17 day old and 2 year old
“I got pregnant and I wanted to abort it, but my husband said ‘No, don’t abort it, it could be a son.’
When I look at my daughter-in-law, I would want her to have one more child after this one, unless the next one is a girl again. Then I would want her to keep having children, up until six, until she has a boy.”
- Manju, age 34, mother of four, grandmother of one
Female community health volunteers (FCHVs)are the backbone of the Nepali health system. Nepal’s 50,000 frontline FCHVs play an important role in contributing to a variety of key public health programs, including family planning, maternal care, sick childcare, vitamin distribution, and immunization coverage. FCHVs are unpaid volunteers, though they do receive training to support their duties. Responsible for door-to-door communication with women, FCHVs have more insights about the inner workings of the family, and women’s preferences, than any other member of the health force. After the earthquake, since so formal health facilities have been destroyed, FCHVs are even more important in providing community-based care.
“I am the oldest FCHV in the district. I started work in 1988, the year that the FCHV program started. At that time it was not very common for women to work outside of the home or even to travel, but still my husband was very supportive.
The FCHV role has changed very much, and today we provide many basic health services to women, from vaccinations to vitamins to [contraceptive] pills and condoms. With each training our responsibilities increase more and more.
Previously people used to feel shy about family planning, but they now know that the size of the family is directly correlated with the happiness of the family. I attribute this to more widespread education of women. I myself have not been educated, but women today have been very well empowered through their education.”
- Bishnu, age 70, Female Community Health Volunteer, Dhading District
“Many men tell their wives that back pain results from sterilization. Some women believe that depo causes hemorrhage. We only provide short term methods at our facility, so women have to go to family planning camps or to the district hospital for long-term methods. The camps come here once a year, sometimes less.”
- Gita, age 29, and Sita, age 31, Female Community Health Volunteers, Sindupalchock District
Family planning campaigns have spread the slogan, “A small family is a happy family,” and promoted a two-child norm, throughout much of the global South. Even in then most remote areas of Nepal, this refrain was repeated over again, and again. Often unaccompanied by much comprehension or explanation, it is a message that began with the Government and has sprawled beyond mountains and roads, through TV, radio, print, and health workers.
“For now, we are satisfied with one child–more than that can be difficult. Difficult to feed them and to have the income to care for them.”
- Sunita, age 23, and Chaba Rai, age 28, wife and husband, Sindupalchock district
“For me family planning is needed for small and happy families. With a small family we can easily fulfill our family demands like education and health. Family planning helps to control the population and when the population is controlled, development is obvious.”
- Anu, age 27, mother of one
“Two children is enough.”
“Family members must actively share family planning knowledge amongst themselves. For example, the mother-in-law should teach her daughter in law, and the mother her small child. This is how we will increase use.”
- Laxmi, age 29, mother of two
When we left Nepal, we watched a plane board from Kathmandu to Sharjah, UAE. Every single person boarding the plane was male, except for two young women. Every single man appeared under the age of 40, most younger than 30. Backpacks were slung over their shoulders and most were dressed in the Western fashion, except for the rare tilak or Brahmin tuft of hair at the back of their head. Each one had a wondrous, shocked expression pasted on his face, as they glanced down repeatedly at their tickets and back again at the boarding sign.
Every month, nearly 16,000 Nepalis travel to the Gulf States for temporary work, and thousands more go to other countries in the Middle East. Almost half of all households have at least one family member who is currently working or has previously worked abroad. Migrants often suffer high levels of abuse and exploitation. Routine harms include contract substitution and fundamental changes in the nature or conditions of work, non-payment of wages, unsafe work conditions, inadequate rest, inhumane housing conditions, and confiscation of identity documents. Hundreds of workers die while working abroad each year, often from work-related causes. Immigrant laborers are traded like currency in the Middle East: 2 Filipinos is equal to one Nepali, one Filipino for two Nepalis. 3 of every 4 day laborers in Kuwait is Nepali, Indian, or Pakistani.
This means that entire Nepali villages are void of young men. In the context of earthquake relief, there is a marked dearth of male laborers to help rebuild. As far as family planning goes, migration patterns have a tremendous impact on adherence and use: Family planning is often discontinued when husbands are abroad, and then women rely on less effective emergency contraception when they return for a visit.
“I haven’t thought about what I will use for family planning now because my husband isn’t here. He’s been working in Kuwait for the past six months.”
“I had the depo injection, but I stopped using it because I had bleeding. My husband said it’s difficult to provide more than three children with good meals and clothing, so I should start the family planning immediately. How will I make sure I can keep getting it, while I’m living in this tent village?”
- Jana, age 33, mother of three children age 5, 6, and 8
We learned a vocabulary new to Nepal since the earthquake, a set of words used to describe the various ways in which a building can be destroyed in an earthquake: pancaked, leveled, sideswept, peeled. We saw and felt immeasurable loss—families broken, people lounging against fallen wood and stone piles, watching the mainly empty road with blank stares. Entire villages are in pieces, with the interior objects of homes abandoned, sitting on the blank foundation as they always were—a wicker basket, an upturned plastic chair.
And yet, there is a palpable sense of keeping on, because there is no other choice. We heard many stories of spirit, of resilience, of kindness, all against the backdrop of apparent hopelessness. Remote communities were shocked and thrilled to see medicine delivered to their homes, eyes wide with the gratitude and surprise that they had been remembered. The Government and its partners met at 5:30am each morning, as soon as the sun was up, endeavoring to operationalize the vast logistical capacity needed to deliver the donations pouring in from multilateral organizations. Workforce capacity remains halted, as frontline workers put their lives back together, but those that serve—at a nominal or nonexistent paygrade—do so because they believe in the health of their community. It is unclear whether some villages will be rebuilt at all, or whether residents will create altogether new lives in the Valleys. These are the new immigrants, migrants in their own country. What is clear, however, is that the Nepali people are finding ways to continue on, to find strength, and to create family. But, to create happy family—whether small or large—women’s voices and stories must have a central role in the ongoing rebuilding efforts.
“We are building our home.We learned how to do it from our parents.”
Grace Lesser is an MBA/MPH candidate at UC Berkeley Haas School of Business and the School of Public Health. She has four years of public health program implementation experience in East Africa, where she focused on health systems strengthening, technology, and maternal health. Her past professional roles have included significant writing and reporting components, including directed marketing and public relations efforts as well as managing strategic communications and knowledge management. She has contributed to public health articles published on platforms such as Nicholas Kristof’s “On the Ground” column in the NYTimes and Forbes.com, and published a Huffington Post column on the Westgate terror attacks. As a health innovations consultant for the One Acre Fund, an agricultural asset financing firm, she designed an ethnographic tool and conducted interviews with women aimed at understanding the primary challenges, preferences, and gaps in accessing family planning in rural East Africa, an experience that directly set the foundation for this project.
Kyla Pearce is a PhD candidate at The Dartmouth Institute for Health Policy and Clinical Practice at Dartmouth College with research interests in women’s decision-making about reproductive health care. She has experience in global reproductive health programming and community-based qualitative research. She has worked for Pathfinder International and for Action Research and Training for Health (ARTH), an Indian NGO based in rural Rajasthan, India through the American India Foundation’s Clinton Fellowship. While working for ARTH, she implemented a qualitative research study about how community health workers counsel women about family planning services, and conducted semi-structured interviews to document examples of violations of women’s reproductive justice. She has also published results of a study examining women’s and healthcare providers’ information priorities about contraception in the scientific journal, Contraception, and an opinion piece about gaps in domestic access to family planning service in the blog, RH Reality Check.