Nepalese culture is one that highly values family, tradition, and custom. Nepalese beliefs about pregnancy, childbearing, and general medicine are strongly influenced by religious beliefs and cultural practices. It is important to understand these influences when providing medical care so that the individual’s beliefs are respected while also promoting the health and safety of mother and baby with evidence-based medicine.
While other religions are also practiced, Hinduism is the primary religion in Nepal. Hinduism is considered as much a social practice as it is a religious practice and thus strongly influences all aspects of life. Karma is the moral system of cause and effect and is a central concept of Hinduism. The belief in karma influences perceptions of illness, health, and death in the way that life events are considered the result of past actions. Another main theme of Hinduism is the concept of purity versus impurity. Accordingly, Hindus may prefer to wash with running water and favor showers to baths. Certain actions, body parts, or objects may also be viewed as impure. Women, for example, are considered to be impure during their menstrual cycle and are isolated until the fourth day, at which point they receive a purification bath.
Ayurvedic medicine is a commonly practiced philosophy of wellness and is the belief that the body is comprised of three forces, called ‘dosha’, that promote health when in balance. Ayurveda includes the use of herbal medicine, lifestyle considerations, and hot and cold theory as methods to treat illnesses. Tibetan medicine is also practiced and is closely related to concepts of the Hindu faith. Tibetan medicine is founded on the belief that the mind creates the body’s condition and that health is ultimately the product of harmony between the body and the universe. Faith healing and the use of Ayurvedic medicine are the most frequently practiced healthcare systems in Nepal, therefore it is important to determine if such beliefs may influence adherence to modern medical treatment.
Some health considerations specific to Nepalese are thalassemia, sickle cell, and several other health risks such as hypertension, obesity, and dyslipidemia, all of which may pose a risk to both mother and baby. There is limited information about the rates of occurrence for thalassemia and sickle cell, but some research suggests that these conditions may be more prevalent in Nepal as a whole, or at least more common in certain regions. Thalassemia can increase cardiac, liver, and endocrine complications in pregnancy and increase the risk of miscarriage. Sickle cell disease may increase the risk of preterm birth, low birth weights, and other complications. For each of the possible health risks listed, screening, prenatal care, and careful monitoring are key to a healthy pregnancy.
Nepalis view pregnancy and birth as very natural processes that are ultimately in God’s hands and as such, no specific prescriptive or restrictive practices are noted regarding pregnancy. In general, not much preparation occurs throughout pregnancy, which could be related to spiritual beliefs, but may also be explained by limited access to resources. In studying the differences between rural and urban populations, the outcome of Nepalese pregnancies is associated with the geographical location in the mountains or hills, lower maternal literacy, lower parental education level, maternal occupation in agriculture, surface drinking water sources, and unimproved sanitation facilities. Women who live in rural areas, are low-income, or are of a lower caste may have additional difficulty accessing any type of antenatal care.
Whether a Nepali woman receives prenatal care appears highly dependent on her socioeconomic status, geographical location (i.e., rural versus urban), and age. Research showed that 84% who gave birth in Nepal over the last 5 years received prenatal care, but often not until the second trimester. Another study found that as little as 29% and upwards of 79% of women in more urban areas did not receive any prenatal care. Younger mothers were found to begin prenatal care earlier, but women who had previously given birth generally delayed or omitted prenatal care altogether. A portion of the findings about prenatal care may be due to religious beliefs that the safety and health of the newborn or fetus are more of a spiritual matter and cannot be externally controlled via medical intervention. An additional explanation may be that cultural norms prevent women from discussing sex or reproduction and consequently limit their autonomy to make decisions about health care.
Beyond prenatal care, Nepalese have many traditions and cultural views that may impact the full spectrum of pregnancy. A common belief is the ‘hot and cold theory’, in which ‘hot’ or ‘cold’ refers to the effect of food, herb, or medicine on the body, rather than its temperature. Hot or cold foods are consumed in correlation to wellness needs, and some foods may be eaten only in certain combinations or during specific seasons. Some examples of cold foods include bananas, citrus, chicken, milk, and many vegetables, and thus the avoidance of certain ‘cold’ foods during pregnancy could leave many women significantly lacking in certain nutrients. Nutrition may be further impacted by the practice of serving men first with women eating last and the least. Of additional concern is the use of certain Ayurvedic herbal medications that may contain lead. Therefore, it is of particular importance to educate Nepali women on the use of certain herbal medications while pregnant and to perform newborn screening. Food and herbal practices vary depending on geography, religion, and caste, so needs should be assessed for each woman individually.
Regarding social structure and gender norms, the patriarch typically heads the extended family, and Nepali mothers are highly respected, especially in the care of their children and daughters-in-law. While little research has focused on the gender preference of children, Nepal is generally classified as having notable levels of son preference. Although daughters are accepted, sons are often more valued because they continue the family name, can perform funeral rituals, and provide support to the elderly. Related to gender beliefs and, in particular, the birth of a son, it is worth noting that Hindus do not traditionally practice circumcision.
In part due to the patriarchal structure, as well as cultural or religious doctrine, Nepali women may feel limited in the ability to make their own decisions regarding contraception, pregnancy, and birth. They may fear that their husbands will abandon them if they do not act according to tradition, and may have little say about intercourse, condom use, or the number of children they bear. Women are expected to bear children and be the primary caregiver, so they may feel that they must accept the pregnancy regardless of their personal feelings. For example, there is the expectation that once married, a woman will get pregnant and give birth, while likely abstaining from contraception use until a son is born.
As noted previously, birth is viewed as a very positive and natural process, but giving birth in a hospital may be an unfamiliar experience for an immigrant, as only 57% of Nepali births occur in a health facility. In Nepal, many rural women may give birth in the cowshed called a ‘goth’. In general, Nepalese women view pregnancy as a natural process, and therefore medical intervention or monitoring is often considered unnecessary. Moreover, a Nepali woman’s spiritual beliefs and notion of being in God’s favor may significantly influence her perception of the health and survival of the newborn. When asked about the value of giving birth in a traditional setting that aligned with religious or cultural beliefs versus considering the outcome of the birth itself, many women indicated that losing a child is believed to be a customary part of pregnancy and childbirth. This statement is reflective of the Nepalese view that the health of the newborn is more likely associated with God’s favor than with medical care.
As tradition and community are so important to Nepalese culture, the birthing process also includes family support and certain expectations. For one, laboring women are discouraged from expressing pain or drawing attention to themselves. It is customary for a female relative, often the mother-in-law, to be present during birth. An older relative or neighbor may also be present and is called an ‘aji’ or traditional birth attendant. It is expected that female family members and friends assist with daily activities and care of the infant postpartum. Traditionally following birth, the new mother will stay with her in-laws’ for 30 days and later stay with their parents for several more days.
Men are often absent from the birthing process, as birth is considered a ‘women’s affair’. In rural Nepal, where many women give birth at home instead of health care facilities, however, the husbands may be the only person available to assist. Over time, this tradition has been changing and Nepali women are increasingly requesting the presence and involvement of the husband during the birthing process.
Following birth, both the mother and newborn are considered impure, and the birthing process itself is considered unclean. New mothers may remain in seclusion at home until a purification ceremony is performed, and others are likely to avoid touching the mother or holding the baby. The newborn is named and purified in a special ceremony, usually 3 to 12 days after birth, and the ceremony is traditionally performed by a priest. After the ceremony, the mother and baby are ‘clean’ and may be touched again. The mother may also be isolated to the cowshed as part of the re-purification process, and cow urine is used to purify the walls of the home. It is considered common practice to bury the placenta.
The newborn may be massaged with mustard oil, which is believed to regulate body temperature, promote weight gain, and prevent infection. Meanwhile, new mothers are fed a diet of lentils and spices such as cumin to stimulate milk production and may also eat a special bean soup, meat curry, and cake made of cashews and coconut to promote breastfeeding. Breastfeeding is viewed positively and typically encouraged for at least six months and even as long as three years. Several Ayurvedic medicines may also be utilized for the new mother including: ‘Janma ghuti’ for digestion, ‘Balmrita’ as herbal medicine, and ‘Jaiphal’, which is nutmeg. Some women are not aware of the importance of colostrum and discard it, mistaking it as insufficient milk, so education may be beneficial.
Healthcare practitioners should be aware of the cultural considerations and variations associated with Nepalese to provide the most culturally respectful experience. Further, care should be taken to educate and improve health outcomes for mother and baby, while being cautious not to disrupt a woman’s sense of tradition, community, and spiritual well-being. The best approach is clearly one that combines an understanding and respectful attitude with a recognition of the areas that may need additional attention and guidance.
References
Cultural Atlas Nepalese. (2019). Retrieved from https://www.crculturevision.com/
Ghimire, P. R., Agho, K. E., Renzaho, A., Christou, A., Nisha, M. K., Dibley, M., & Raynes-Greenow, C. (2017). Socio-Economic Predictors of Stillbirths in Nepal (2001-2011). PloS one, 12(7), e0181332. doi:10.1371/journal.pone.0181332.
Kaphle, S., Hancock, H., & Newman, L. A. (2013). Childbirth Traditions and Cultural Perceptions of Safety in Nepal: Critical Spaces to Ensure the Survival of Mothers and Newborns in Remote Mountain Villages. Midwifery, 29(10), 1173–1181. doi: 10.1016/j.midw.2013.06.002.
Leone, T., Matthews, Z., & Zuanna, G. D. (2003). Impact and Determinants of Sex Preference in Nepal. International Family Planning Perspectives, 29(2), 69. doi: 10.2307/3181060.
Paudel, M., Javanparast, S., Dasvarma, G., & Newman, L. (2018). A Qualitative Study About the Gendered Experiences of Motherhood and Perinatal Mortality in Mountain Villages of Nepal: Implications for Improving Perinatal Survival. BMC Pregnancy and Childbirth, 18(1). doi: 10.1186/s12884-018-1776-3.
Sickle Cell Disease and Pregnancy. (2019, October 21). Retrieved from https://www.cdc.gov/ncbddd/sicklecell/pregnancy.html
Tsironi, M., Petrakos, G., & Andriopoulos, P. (2016). Pregnancy in Women with Thalassemia: Challenges and Solutions. International Journal of Womens Health, 8, 441–451. doi: 10.2147/ijwh.s89308.