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Birth In Rural Nepal: The Most Dangerous Day

In August 2009, freelance photojournalist Toni Greaves traveled to rural Nepal on assignment for the Bill & Melinda Gates Foundation's Living Proof Project. This is the story she documented about birth in rural Nepal, and the country's efforts to combat their high maternal mortality rate.

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    In 2009, photojournalist Toni Greaves traveled to Nepal to document birth in a rural village. She followed the story of 19-year-old Maheshwori Devi Bishwokarma, who almost died during the birth of her first child at age 16 and was pregnant with her second.
    All photo by Toni Greaves/Reportage by Getty Images/Reportage by Getty Images
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    Most women in Nepal give birth at home, without the help of a skilled, or even a trained, attendant. Many women are forced to give birth in a cow shed because they are considered unclean while menstruating and while in delivery.
    Photos by Toni Greaves/Reportage by Getty Images
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    Despite being three days past due with her second child, Maheshwori continues to work chopping wood and herding goats, scratching out a living in Dikha Village, in the Himalayan foothills of Nepal. Her husband, who lives and works in neighboring India, comes home once a year.
    Photos by Toni Greaves/Reportage by Getty Images
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    Maheshwori was married at 15 and gave birth to her first child, a girl, at 16. The birth occurred in a cow shed and took three days because the baby was breech. The community thought she would die.
    Photos by Toni Greaves/Reportage by Getty Images
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    An aid worker examines Maheshwori and determines that her unborn baby is also in a breech position. Because of the dangers associated with such a delivery, the aid worker makes a case to the village elders that a skilled birth attendant should be brought in to assist with the birth, rather than relying on an untrained traditional birth attendant.
    Photos by Toni Greaves/Reportage by Getty Images
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    Hearing that a skilled birth attendant is visiting the village, pregnant women flock to the local sub-health post to be examined by the nurse-midwife. She was brought in from a village three hours away in order to deliver Maheshwori's baby.
    Photos by Toni Greaves/Reportage by Getty Images
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    The birth of Maheshwori's first daughter two years ago nearly killed her. Maheshwori is terrified that the same thing will happen again. "I am very, very scared. I just might die this time."
    Photos by Toni Greaves/Reportage by Getty Images
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    Maheshwori labors, a few hours away from giving birth.
    Photos by Toni Greaves/Reportage by Getty Images
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    The local sub-health post for the village has very basic facilities for health care, although no doctor. A hospital with one doctor is a five-hour walk away. The nearest hospital able to perform a cesarean is a six-hour drive away, although families from the village can't afford the cost of the drive
    Photos by Toni Greaves/Reportage by Getty Images
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    Yasodha Ojha, a skilled birth attendant, delivers nearly 50 babies each month and is known throughout the district for her birthing skills. The birth is still not easy.
    Photos by Toni Greaves/Reportage by Getty Images
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    Maheshwori meets her second daughter, Seema, for the first time. She is disappointed that the child is a girl, and says that if she gives birth to four to five girls without any boys, her husband will leave her and remarry.
    Photos by Toni Greaves/Reportage by Getty Images

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What was it like for you covering this story?

Toni Greaves: Women in rural Nepal typically give birth in the family cow shed, so I expected that the birth would happen that way. In Nepal (and other places, frankly), when women are menstruating or giving birth, they're considered to be ritually polluted and must stay outside of the home, often in cow sheds or cement rooms near toilet facilities.

An aid worker examines Maheshwori and determines that her unborn baby is in a breech position. Because of the dangers associated with such a delivery, the aid worker makes a case to the village elders that a skilled birth attendant should be brought in to assist with the birth, rather than relying on an untrained traditional birth attendant. i i

An aid worker examines Maheshwori and determines that her unborn baby is in a breech position. Because of the dangers associated with such a delivery, the aid worker makes a case to the village elders that a skilled birth attendant should be brought in to assist with the birth, rather than relying on an untrained traditional birth attendant. Toni Greaves/Reportage by Getty Images hide caption

itoggle caption Toni Greaves/Reportage by Getty Images
An aid worker examines Maheshwori and determines that her unborn baby is in a breech position. Because of the dangers associated with such a delivery, the aid worker makes a case to the village elders that a skilled birth attendant should be brought in to assist with the birth, rather than relying on an untrained traditional birth attendant.

An aid worker examines Maheshwori and determines that her unborn baby is in a breech position. Because of the dangers associated with such a delivery, the aid worker makes a case to the village elders that a skilled birth attendant should be brought in to assist with the birth, rather than relying on an untrained traditional birth attendant.

Toni Greaves/Reportage by Getty Images

Maheshwori gave birth to her first child, at age 16, in the family cow shed. The birth took three days, as the baby was breech, and she almost died. At age 19, her second child was also determined to be breech, so she was very fortunate that the elders of her village approved her to deliver at the local sub-health post. There are continual efforts in education, but traditional beliefs can make change challenging sometimes. Basically she was very lucky.

Was shooting this story hard for you in any way? What did you learn from it?

The main challenge was really the fact that you can't guarantee when a baby will arrive. We had been loosely following a few different women who may have delivered during the time we were there, but there's still the possibility that no babies could have arrived during our trip.

It gradually became clearer that Maheshwori would likely deliver, so we focused more on her and were very lucky that Seema (her new daughter) decided to come into the world during our stay.

I learned a lot about the challenges these girls/women face and how restricted their lives are. These teenage girls don't have much time to be girls before they become mothers.

Had you ever shot any stories on birthing before? If so, how was this assignment different?

I had previously photographed a home birth in New York City. Photographing birth with a midwife in a beautiful loft in Soho was certainly visually very different than in a small sub-health post in far-western Nepal. But really, what the women were going though physically in that moment was the same. Neither received anything to ease the pain during the birth, and both babies were delivered in the most natural way.

The major difference was the access to extra services should anything go wrong. Where Maheshwori lives in Nepal, the nearest hospital that could do cesarean, should it be needed, is in a town a six-hour drive away. Most people can't afford the cost of a car ride to a hospital, so that's not even part of the picture. Which means that the consequences, if complications occur, are usually very dire. Even a basic hospital with one doctor is a five-hour walk away.

Having experienced this birth in Nepal, has it made you think differently about women's health care in the Western world?

There is so much that we take for granted in our culture. In the U.S., health care still very much relates to one's financial situation — which is not so much the case in Australia, where I'm from, or the United Kingdom, where I've also lived. The bottom line, though, is that everybody deserves access to good health care.

Images from Greaves' story have been recently selected to appear in the Communication Arts annual photo issue.

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