At only 16, Deepa Nepali has two children. Deepa, carrying her 13-month-old daughter, told IRIN in a remote village in northwest Nepal that she constantly suffers heart problems and stomach-ache, and most of all from uterine prolapse.
About 10 percent of women, especially young mothers, suffer from uterine prolapse in Nepal, according to the country’s Tribhuwan University Institute of Medicine. In extreme cases, uterine tissue protrudes from the vagina causing extreme discomfort.
Deepa is malnourished and cannot afford healthy food. She was only 14 when her impoverished parents married her off to reduce their financial burden as they could not provide for her five brothers and sisters.
"Many young girls here die after delivering their first child and I don't know how long I will survive because I get sick all the time. I always feel weak," said Deepa, who lives in Accham district, 700km northwest of the capital, Kathmandu.
In the remote villages of Accham, many girls aged between 12 and 15 marry and have children. Most women, including underage mothers, deliver their children without any skilled birth attendant and are usually assisted by female relatives and neighbours who lack knowledge of safe and hygienic practices.
According to the government's Demographic Health Survey, more than 88 percent of deliveries take place at home and 8 percent of mothers deliver their babies with no assistance.
The consequences are deadly - excessive bleeding (postpartum haemorrhage), tetanus, uterine rupture and pneumonia, among others, which damage young mothers’ health and eventually kill them.
According to the Ministry of Health, nearly 6,000 women die every year in Nepal due to pregnancy-related complications and a lack of post-delivery healthcare.
Women’s rights activists claim that it is not poverty per se but gender discrimination - deeply rooted in Nepalese society – that encourages young marriages, which result in maternal deaths.
"The consequences are that young girls are the ones to suffer the most in the end for their family's poverty and traditional discrimination against them," said Rupa Auji, a local activist.
Deepa Bohara, an aid worker with the Gangotri Rural Development Forum, which focuses on women's empowerment in Accham, said the key reasons for maternal deaths in rural Nepal had been lack of access to effective maternal health services and skilled medical workers in the villages. “But the dominating cause is the low value of girls in our society," Bohara said.
Janaki Luhar was only 15 when she got married three years ago and now has two children. "We are treated worse than our buffaloes," Luhar told IRIN.
She had to start working on the farm and rear buffaloes only five days after the delivery and suffers from uterine prolapse due to lack of rest and care after delivering her child.
According to the forum, young mothers sleep in the cold cowshed or in quarantined mud houses with their infants and often suffer from severe pneumonia, diarrhoea and snake bites. "Nearly 50 girls and young women have died in the last two years from snake bites and cold," said Luhar.
|We are treated worse than our buffaloes|
Luhar recounted how the local girls and women often have to sleep in the cowshed when they are menstruating. Under Nepal’s tradition of Chaupadi a woman is considered impure and cannot come near the family house and has to be isolated for more than 12 days when she is having her periods.
But Luhar’s 35-year-old mother-in-law, Jaldhara, was adamant in her support for local traditions. "This is our custom and we cannot make our gods angry by allowing the impure daughters in our house," she said.
Despite decades of awareness-raising efforts and empowerment training for local women, health workers and women’s rights activists find it difficult to change the social mindset in villages where illiteracy is high and poverty is rampant.
Dire shortage of health services
"We can't just blame the negative Nepalese traditional practices against girls and women in the remote villages because their backwardness is caused by their financial hardship and lack of access to reliable maternal health services," said Tara Datta Pant from Team Hospital in Dadeldhura, Accham’s neighbouring district.
Accham has a district hospital but only a handful of nurses and not a single doctor. Most of the girls and women suffering from complications have to walk between eight hours and three days and then travel by bus for several hours.
"Many have died before reaching the hospital," said Pant, adding that most maternal deaths were often under-reported and unrecorded.
"I wish we could do more to save the lives of so many young mothers but we are already so overloaded with our work in this district," said Abhinesh Dhital, a doctor from Team Hospital, which performs nearly 1,000 deliveries every month.
About 400,000 people from the remote villages of Doti, Dadeldhura, Baitadi and Bajhang rely on the hospital for treatment - for maternal and other health problems.
|I wish we could do more to save the lives of so many young mothers but we are already so overloaded with our work in this district|
The government lacks resources and is trying to provide remote villages with reproductive health services through its mobile health clinics, aided by the United Nations Population Fund Agency (UNFPA) and Humanitarian Aid Department of the European Commission (ECHO).
"UNFPA is supporting the government of Nepal in increasing access to skilled birth attendants to contribute to reducing the maternal mortality ratio," said the agency's officer Peden Pradhan.
Since July 2006, UNFPA and the government have been organising reproductive health services in six of Nepal's most remote districts with a focus on treating girls and women with uterine prolapse problems.
"Increased access by all women, especially those in rural areas, to reproductive health services is essential to preventing this condition," said Junko Sazaki, UNFPA representative in Nepal, urging the elimination of child marriages.