Think Equal: women's health, Nepal

Well-being is not just the absence of illness and injury.

Gender equality, with investment in gender-responsive services and infrastructure that meets the needs of women and girls, is essential for a world where all women achieve the highest possible standards of physical, mental, reproductive and sexual health throughout their lives.

As the global voice for women’s health, FIGO believes that the challenges women face – in their choicespathologies and safety – cannot be solved in clinical isolation.

We asked Dr Kusum Thapa, President of NESOG (Nepal Society of Obstetricians and Gynaecologists), National Coordinator for FIGO's PPIUD project in Nepal, and Senior Maternal Health Advisor at Jhpiego, about the barriers she sees to equal access of public services and sustainable infrastructure in Nepal, and innovations that are raising the status of women.

The theme of International Women’s Day this year is ‘Think equal, build smart, innovate for change.’ What does this mean to you in the context of women’s health?

Collective action is our shared responsibility, driving a gender-balanced world.

As women in medicine, we want to protect, promote and advance women’s health in general. To do this, we need to be able to gender balance the workspace: to design, plan and implement innovative solutions that address the emergent and intractable women’s health problems on a global scale.

Change should be based in the principles of integrated innovation, multisector collaboration, responsive design and rigorous evaluation of what is effective in the local context. Not only in maternal health, but women’s health in the broadest sense. We want to celebrate the social, economic, cultural and political achievements of women in all the sectors.

Access to public services is essential for health and wellbeing, particularly primary care: but there is often a dangerous gap between men and women, rural and urban. Please could you address the biggest challenge you see for women in Nepal when it comes to accessing public services?

Gender stereotyping and discrimination are the biggest challenges I see for women in Nepal when it comes to access. It creates obstacles, not only to reproductive health services like contraceptive and abortion, but public services in general.

Stereotyping women as mothers within marriages is seen in policy and practice across Asia and the deeply patriarchal structure we live in. Marital status remains a pre-requisite for women to obtain sexual and reproductive health (SRHR) services in Nepal. Single women, unmarried women and women with different gender identities are unable to access SRHR services to the same extent.

Women are still dying of traditional harmful practices like Chaupadi (menstrual hut) and around 41 percent of women are married before the legal age, further increasing the rate of teenage pregnancy and maternal mortality.

Lack of education, infrastructure, lack of commitment and strong political will to implement on the ground further perpetuates the magnitude of the problems, despite strong polices in paper.

How is NESOG working to advance gender equity when it comes to access to public services?

NESOG is committed to advancing gender equity and access to public services. We have trained our frontline providers in gender sensitivity, and our approach to women’s health has always been women-centred. We are constantly striving to attain target 5.6 of Goal 5 on the 2030 Sustainable Development Agenda and empower women to make informed decisions regarding health services.

Evidence demonstrates that where women’s right to health, including sexual and reproductive health, is upheld, they are more able to claim their education, work, and equality within the family and beyond. Approaching these issues in an integrated way is critical.

One of the ways we do this is through partnering with FIGO on the Postpartum IUD (PPIUD) Project. The project increases the capacity of healthcare workers to provide more comprehensive family planning options, specifically in the postpartum period.

OBGYNs are on the frontline of women’s health, and change. What is the most exciting innovation you have seen when it comes to accelerating progress for gender equality in your field?

The most gratifying and innovative work for me has been in response to gender-based violence in Nepal. Practices such as early marriage, forced marriage, non-spousal violence and other forms of exploitation still prevail, and I was lucky enough to take a lead in the healthcare response.

The Nepalese government has taken important steps to combat gender-based violence, and NESOG has been supporting a national protocol and training package on 'Health Response to Gender Based Violence for Frontline Health Workers' alongside Jhpiego and UNFPA. I feel fortunate to be working in an organisation which has these principles at heart. Nepal now has a Domestic Violence Act, government funding for programs on gender violence, and a hotline for survivors to register complaints.

We need to ensure that frontline health workers are equipped with the knowledge and skills to care for women suffering from gender-based violence. There is no unified training for health care workers to identify survivors, provide medical and emotional support, or carry out the necessary documentation and referrals. In many cases, medical evidence is not properly recorded, leading to low prosecution and conviction rates for rape cases.

Can you share a story that illustrates why healthcare systems must respond more directly to the specific healthcare needs of women and girls?   

It is a chilly night in rural hospital in Nepal. I have been asked to attend a young woman who is lying in a pool of blood as nurses rush around her. A mother of three small daughters, she is four months pregnant and badly beaten. After resisting her husband’s demands to terminate the pregnancy, she has paid a heavy price.

The woman had visited the health facility twice before, once with a black eye, once with bruises all over her back and arms. She said that she had fallen down the stairs.

If the provider had spent more time with her to understand the situation, she might not have been a victim of a repeat incident. The role of medical staff in identifying violence and providing non-judgemental, supportive treatment is key - but all too often this is done poorly, if at all.

Fortunately, Sita survived. But despite all our efforts, we could not save her unborn child.

Gender-based violence is a grave social and human rights concern affecting virtually all societies. Effective plans to strengthen health facilities and equip health workers to deal with gender-based violence are of utmost importance and could save lives.