How I Got My Mother-in-law to Care About My Health: Measuring Impact of Women’s Groups on Maternal Health in Nepal

The Safe Motherhood Initiative is 20 years old and the Millennium Development Goals (MDGs) are reaching their ‘due-date’ (2015)! Too often women in developing countries do not have ‘rights’ over their own body: ‘When to get pregnant, how often and when to access health services’. To this end in 1997 Green Tara Trust (GTT), a Buddhist charity, focused on the (basic) human right issue of women’s reproductive and maternal health in Nepal (www.greentaratrust.com). GTT build on the Safe Motherhood message that health interventions in developing countries should be community-based, culturally appropriate and contain a cost-effective component.

Aside from advocacy, research constitutes an important component of GTT’s activities.  A study associated with GTT found that a major barrier to accessing maternal health services in rural Nepal was the lack of support of mothers-in-law. The latter were the main decision-makers and controlled the money in the household.

Thus in 2007 a community intervention (5 years) was implemented with community groups (including men, mothers and their daughters-in-law) to reduce said barriers and improve the uptake of maternal care in rural Nepal via health promotion. Health promotion focuses on enabling people to increase control over and thereby improve their health and its social and environmental determinants.

My collaboration with GTT began as a Research Assistant (University of Aberdeen, Scotland) and grew into a PhD at Bournemouth University evaluating this intervention. I find GTT’s approach at a community level interesting – as it promotes evidence-based practice in the community supporting two health promoters for a rural population of about 10,000. Also at a personal level, I grew up in Kenya, and in the past few years have spent considerable time in Nepal.

Nepal (population of 27 million) is a fascinating country in which to conduct research. It has been in transition since 1990, from an authoritarian Hindu kingdom to a constitutional monarchy and now a republic. The massacre of the royal family in 2001, a decade-long civil war (1996-2006) between Maoists and the government that ended in a peace agreement in 2006 have also stalled progress in health indicators in Nepal. Currently, the country is divided not only geographically but also by caste, ethnicity, religion and a federal system. Minorities, lower-caste people and rural residents have been historically marginalized. Nepal is the 22^nd poorest country in the world with 25.2% of people earning less than the US$1.25 per day poverty line. Despite these odds it has performed well in certain health outcomes, such as a reduction in maternal mortality to 170/100,000. Now that the conflict is over, it is imperative that research continues to improve health and services for its largely rural communities and that social policy in Nepal can be shaped to be ‘inclusive’ of those marginalised.

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Sheetal Sharma a Bournemouth University PhD candidate jointly supervised by ISGlobal’s Dr. Elisa Sicuri, a specialist in health economic evaluations of interventions in low-income countries: Under the supervision of Dr. Sicuri an innovative approach the ‘Difference-in-Difference Technique’ was applied to measure the impact of the community-based maternity intervention in Nepal. This research has successfully been presented at international conferences (Society for Social Medicine (London); University of Berkeley (USA); Nepal’s National Health Promotion Conference (Kathmandu); 2012 Spanish Stata Users Group meeting and the European Congress on Tropical Medicine & International Health (Denmark).