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The influence of a patriarchal culture on women’s reproductive decision-making: exploring the perceptions of 15 Nepali healthcare providers

29 September, 2016

The influence of a patriarchal culture on women’s reproductive decision-making: exploring the perceptions of 15 Nepali healthcare providers

Insights into the influence of a patriarchal culture on women’s reproductive decision-making can, for healthcare providers and development workers, bring about an understanding of the complexity in society.

Magdalena Mattebo1 PhD, RM, RN.
Madeleine Lindkvist2 MSc, RM, RN.
Christina Pedersen3 MSc, RM, RN.
Jamuna T Sayami4 MSc, RN.
Kerstin Erlandsson5 PhD, RM, RN.

 
1. Senior lecturer, School of Education, Health and Social studies, Dalarna University Högskolegatan 2, 791 88 Falun Sweden. Email: magdalena.mattebo@kbh.uu.se
2. Midwife School of Education, Health and Social studies, Dalarna University Högskolegatan 2, 791 88 Falun Sweden. Email: madde@certit.se
3. Lecturer, School of Education, Health and Social studies, Dalarna University Högskolegatan 2, 791 88 Falun Sweden. Email: cpn@du.se
4. Health learning material unit coordinator, National Centre for Health Professional Education, PO Box 2533, Maharajgunj, Kathmandu, Nepal. Email: jamunats10@gmail.com
5. Associate professor and senior lecturer, School of Education, Health and Social studies, Dalarna University Högskolegatan 2, 791 88 Falun Sweden. Email: ker@du.se

This study was funded by the Swedish International Development Cooperation Agency (SIDA). The authors would like to thank all informants for sharing their views and thank those providing contact details of potential participants. A special thanks to Prem Dangol and family who provided contacts, transport and information.

Abstract 

Background. Studies show that patriarchal traditional family structures restrict women’s ability to decide for themselves about family planning and pregnancy. This affects both women’s and children’s health. 

Aim. To explore healthcare providers’ perspectives on the traditional patriarchal family structure in Nepal and its impact on women’s decision-making authority regarding sexual and reproductive health. 

Method. A qualitative approach was used in this study. A total of 15 healthcare workers with knowledge of English were recruited through snowball sampling, starting with friends, business contacts and workmates in Kathmandu. The inclusion criterion for the healthcare providers was sufficient knowledge of the English language to the extent that an in-depth interview could be conducted. To enable respondents to express their perceptions, semi-structured interviews formed the basis for data collection. Data were analysed using content analysis. Ethical approval was obtained from the research ethics committee at Dalarna University in Sweden and from the Institutional Review Board at Tribhuvan University, Institute of Medical Research Department in Nepal 

Findings. Two generic categories and eight sub-categories offer insight into the practitioners’ perceptions concerning the influence of a patriarchal family structure on women’s decision-making. The patriarchal traditional family structure was perceived to be both a barrier and a support for women’s decision-making authority regarding sexual and reproductive health. The study showed that there is an ongoing change in the Nepalese society. 

Clinical implication. Insights into the influence of a patriarchal culture on women’s reproductive decision-making can, for healthcare providers and development workers, bring about an understanding of the complexity in society. The study can be used for reflections on why international and national reproductive healthcare policies promoting gender equality and empowering women take time to implement because of a range of cultural perspectives.
 
Key words: Patriarchal structures, traditional family structures, women’s health, maternal health, Nepali families, decision-making, Nepali women’s autonomy, evidence-based midwifery

Background

In 2015, Nepal experienced two major earthquakes which affected the country greatly, including the education and public health systems. The public health consequences have been significant. More than 1000 health facilities, mostly village health posts in hard-to-reach areas, have been destroyed. Of the 351 facilities with emergency obstetric, maternal and neonatal care before 2015, nearly one-third were destroyed and many more damaged. UNICEF estimated that, in the worst hit areas, 12 babies were born every hour without basic healthcare facilities (Simkhada et al, 2015). 

Before the earthquake, maternal health had improved and the maternal mortality rate (MMR) had declined and stabilised; it was reported to be 258 deaths per 100,000 live births (WHO, 2014). Most likely the MMR was higher in remote areas where 80% of the 28 to 30 million people resided and most women birthed (WHO, 2015). 

Regarding the reproductive lives of women in Nepal, a girl often enters into marriage at a young age and becomes a mother in her teens. The marriage is usually with someone of her own caste and ethnic group. Women in Nepal traditionally give birth for the first time between the age of 15 and 19 years. A total of 39% of women aged 15 to 19 in 2011 reported to be either pregnant with their first child or had already become mothers (Ministry of Health and Population (MoHP), 2012). Furthermore, the women were reported to have a lower social rank and status when compared to Nepali men. They tended not to attend school or left in the early grades. The result was that girls were illiterate to a higher extent than boys, which had a negative effect on girls’ and women’s decision-making authority later in life (Bajracharya and Amin, 2012; Regmi et al, 2010). Sexual and reproductive health and rights (SRHR) has been taught in the 10th or 11th grade, when many girls have already dropped out of school (Kaufman et al, 2012). 

Knowledge about the subject (Mattebo et al, 2015) and access to SRHR was considered poor, especially in rural areas (Khatiwada et al, 2013; Kaufman et al, 2012). Abortions have been legal in Nepal since 2002, but a lack of knowledge about the legalisation, plus the social stigma, results in illegal and unsafe abortions (MoHP, 2012; Rocca et al, 2013). 

According to UNFPA (2014), in a patriarchal society girls and women are often discriminated by culture. The influence of a patriarchal culture on women’s reproductive decision-making has previously been described from a gender inequity perspective. In a population-level based study from  covering Namibia, Kenya, Nepal and India, extended and patriarchal family structures restricted women’s ability to decide for themselves about family planning, pregnancy and antenatal care (Namasivayam et al, 2012). In turn, this restriction affected the health of women and their children (Dhakal et al, 2013; MoHP, 2012). 

The impact of culture on women’s reproductive decision-making is, according to the Ecological System Theory (Bronfenbrenner, 1977), multidimensional and interlinked with a range of differing perspectives. Regarding Nepali society, the Government of Nepal has provided good-quality reproductive health care to women during the last decades (MoHP, 2012) and yet the MMR and neonatal mortality rate have remained at a fairly high level (WHO, 2014). The Government of Nepal and bilateral donor organisations have striving to implement the national reproductive health strategy at governmental health facilities, but there is more to do (UNFPA, 2014). 

The successful reduction of the MMR in Nepal during the last decade has been explained by several factors, including the set-up of skilled birth attendants (SBAs), training of healthcare providers (WHO, 2014; Baral et al, 2010), the end of the armed conflict in 2006, infrastructure improvements (MoHP, 2012; Devkota and van Teijlingen, 2010) and the maternity incentive scheme introduced in the country in 2005. This scheme offers mothers incentives when they come to a health facility to give birth (Ensor, 2009). 

Gender inequities and women’s poor access to reproductive health care can be argued to be related to different levels, structures and systems in society. The perspectives at individual and relational levels of gender inequity  are  interlinked with multidimensional perspectives (Bronfenbrenner, 1977); in Nepal, the deep patriarchal family traditions affect the individual, their relations and the economic, educational, social and political systems, plus the system of justice (Kaufman et al, 2012). At an individual and relational level of society (Bronfenbrenner, 1977), in the patriarchal traditional family structure after marriage, that is usually arranged, the girl moves in with her husband’s family and they live together as an extended family; this includes her husband’s parents, his brothers and their wives and children (WHO, 2015; MoHP, 2012; Regmi et al, 2010). 

However, it is now becoming more common for couples to live as single families; the woman moves with her husband to their own apartment in the city to get closer to education, health service and work opportunities (Williams et al, 2014). At a societal level, a stagnation of the MMR and NMR rates for the population in remote areas has been noted and explained mainly by either low performance of healthcare providers, lack of trust in staff, or shortage of staff (WHO, 2014). In Nepal, other studies focus on the inaccessibility of health services (Paudel et al, 2012). At an individual and relational level (Bronfenbrenner, 1977), healthcare providers as individuals are part of a strong tradition and likely to be part of a patriarchal family structure; furthermore, at a societal level, the healthcare system is part of interlinked cultural perspectives and a multidimensional system (Bronfenbrenner, 1977). Health care provider performances could, therefore, adversely impact on women’s decision-making authority. Similar gender biases have been described in delivery care in hospital settings (Hatamleh et al, 2008). The aim of this study was to explore healthcare providers’ perspectives on the patriarchal traditional family structure in Nepal and its perceived impact on women’s decision-making authority regarding sexual and reproductive health.

Methods

Study design and ethical approval
A qualitative approach was used in this study. In order to give respondents the opportunity to express their perecptions, semi-structured interviews formed the basis for data collection. This gave respondents the opportunity to develop their answers (Polit and Beck, 2012). Content analysis was used (Elo and Kyngäs, 2008). The author followed the World Medical Association’s (WMA) (2015) guidance regarding ethics, and the Helsinki Declaration was followed regarding informed consent, informed choice, confidentiality and the possibility to withdraw from the study at any time (WMA, 2015). Ethical approval was obtained from the ethics research committee at Dalarna University in Sweden and from the Institutional Review Board at Tribhuvan University, Institute of Medical Research Department in Nepal.

Setting
This study was conducted in different health facilities, institutions, health posts, birthing centres (government and private), and community hospitals in rural and urban Nepal where the informants worked. Interviews were conducted in cafés, separate rooms in hospitals, or in offices. The researcher gained access and permission to undertake interviews on location at the various healthcare establishments.

The interviews with informants with urban working experience were conducted at three different hospitals, a private and a government hospital in Kathmandu and one rural government hospital. The interviews with informants with rural working experience represent healthcare personnel from one private, two government hospitals, a 15-bed community hospital, and from five health posts ranging from 120km to 310km from Kathmandu in both hilly, mountainous and jungle areas.  

Study population
A total of 15 informants were identified through informal and formal contacts in Nepal. Recruitment of participants was made by snowball sampling that started with friends, business contacts and workmates in Kathmandu (Polit and Beck, 2012). The snowball sampling was a process where the researcher asked the informants if they knew someone appropriate for further interviews, until the predetermined number of interviews had been obtained (Polit and Beck, 2012). The informants received information about the study both verbally and in writing. They were reassured that  participation in the study was completely voluntary and that they could end the interview at any time without giving a reason. In six interviews, the researcher met the informants who worked or had been working at rural hospitals and health posts while they were in Kathmandu for training, education or visiting. 

The study population included 15 healthcare providers, aged 23 to 63 years, three men and 12 women of different educational levels and different levels of experience. The working experience of the informants ranged from one to 23 years. The inclusion criterion for the healthcare providers was knowledge of  the English language to an extent that an interview could be conducted, and that participants showed an interest in sharing their perceptions. The exclusion criterion, hence was a lack of English to the extent that a meaningful interview could not take place, and a lack of interest in sharing their perceptions.

Interview guide
An interview guide with semi-structured questions was used. The guide had been used in similar settings and was modified to the context of Nepal after pilot testing. Three pilot interviews were conducted to test the interview guide and the guide was adjusted to suit the topic more precisely in the context of Nepal. 

Data collection
A pilot study took place among nursing students at Tribhuvan University in Kathmandu to test the interview guide. Initially, information about the study and interview guide was forwarded to the healthcare facility and healthcare provider in order to provide a clear picture of what the interviewer intended to investigate (Polit and Beck, 2012).  

The selected informants were invited and were free to choose where the interview should take place (Polit and Beck, 2012). After participants were informed and signed a consent form, which indicated that the interview would be tape-recorded, interviews began and lasted 40 to 110 minutes. All tapes were transcribed verbatim. In one interview, detailed notes were taken since the informant did not feel comfortable being recorded (Polit and Beck, 2012). 

The interviews started with the collection of demographic data relating to the participant and the clientele they served, in particular their caste and economic and working situation. Questions focused on the informant’s perceptions of how cultural factors and patriarchal traditional family structure impacted on women’s decision-making. These semi-strucutred questions were followed up by asking: 
‘Can you please tell me more about…’, for example, differences between urban and rural areas and ethnic and religious groups. 

The informants were asked to give examples from their own experiences. Interviews continued with questions regarding the young women’s situations and their relations with their in-laws, and how it was to have a baby girl compared to a baby boy. The interviews ended by asking  if the informants had any suggestions about how to make it easier for women to reach and receive health care, and if there was anything they wanted to add. The interviews were recorded in English using recording devices and taking notes. 

A total of 12 of the informants requested  a copy of the transcripts of the interviews. The second author (ML) transcribed all the material independently and had the opportunity to call or write back to the informants if there were any ambiguities (Polit and Beck, 2012). The co-authors were involved in the analysis to ensure accuracy.  

Analysis

Firstly, the data from each interview were read several times, in order to become familiar with the content. The second step was searching for meaning units. Meaning units are where statements that contained descriptions corresponding to the aim are identified. When meaning units were identified and selected, the process continued by condensing long answers to the essential sections. The condensed meaning units were then grouped according to similarities in the content and labelled with a code. The codes could be described as a connection for further analysis between the meaning unit text, to a further abstraction into sub-categories. The sub-categories included codes with similar content. 

The analysis process continued to understand the codes and sub-categories’ underlying meaning. The abstracted content of the sub-categories formed the generic categories and the main category. The meaning of the generic categories and the main category that emerged was verified in the condensed meaning units, codes and sub-categories. The analysis was made as an open and critical dialogue between the authors until the final analysis resulted in consensus. In the last step, different perceptions in the sub-categories were illustrated by quotations that indicated the variation in perceptions. The analysis, interpretation and abstraction resulted in eight sub-categories, two generic categories and a main category that combined the emerged generic categories (see Table 1).

Findings

The result from the interviews is captured in the main category: ‘Patriarchal traditional family structure has great impact on women’s decision-making authority’. The patriarchal traditional family structure was described as a barrier for women’s decision-making authority, and hence a barrier to women’s sexual and reproductive health. At the same time, the patriarchal family structure was described as supportive to women’s sexual and reproductive health, if a family decision was made on the woman’s behalf while taking her will into account.  

Patriarchal traditional family structure – a barrier for women’s decision-making authority 
This category is comprised five sub-categories: ‘Husband, family, and in-laws make decisions’, ‘Age and education level affect family members’ status’, ‘Mother-in-law’s experience provides guidance’, ‘Families preserve traditional beliefs’, ‘Women’s value and consideration are low’.

Husband, family, and in-laws make decisions
The healthcare workers’ perceptions were that women’s decision-making authority regarding their baby’s and their own health depended on the family structure, be it joint or single family structure, their financial situation and the support given by the husband. The woman’s decision-making authority was deprived if the family followed traditional ways: 
“It happens that the family doesn’t allow her to go to health care, because I have seen women who say: ‘I want to come to the hospital, but I’m not allowed’”(informant 6). 

The healthcare providers’ perceptions were that young girls in poor areas were especially vulnerable. They got married early and might be forced into pregnancy or abortion by in-laws and husbands, and they might not allow her to attend antenatal visits: 
“When a girl get married, she is expected to have a baby in the first year of her marriage; they (the girls) are obligated in the first year. Pressure from mother-in-law, husband’s family” (informant 7). 

Age and education level affect family members’ status 
The healthcare providers’ perceptions were that the family members’ education level, background, and financial situation influenced women’s decision-making authority. Authority was furthermore limited by the size of the extended family; in particular, young, uneducated women remained unaware about reproductive issues, such as family planning and the advantage of child spacing. Sexual and reproductive health and human rights were not considered a topic open for  discussion in Nepal society. Uneducated family members were described as preferring traditional rather than modern medicine and did not understand the healthcare system:
“Family and education level could be barrier in rural areas. The in-laws might not be educated; this is the problem for women” (informant 9). 

Mothers-in-law’s experience provides guidance 
The healthcare providers’ perceptions regarding the Nepalese culture were that young women respected the standpoints of their mothers-in-law. A woman being allowed to decide about seeking health care for herself or her children depended on the mutual understanding and relationship between the daughter-in-law and the mother-in-law. The mothers-in-law, especially in conservative families and in more vulnerable situations, discouraged pregnant women’s choice of hospital births, which were considered a waste of money: 
“If her elder daughter-in-law give birth to a healthy male child at home then she says why to spend money to go outside the home, she delivered normally, you can also deliver normally” (informant 14). 

Some families were scared of healthcare clinic staff, since they believed it necessitated surgery and medication and that was not preferred on behalf of a wife or daughter-in-law: 
“They have so much fear inside for the hospital, for the doctor. That’s why they came very late” (informant 4). 

Families preserve traditional beliefs
The healthcare providers’ perceptions were that traditional family structures were influenced by unspoken traditional beliefs and traditional thinking and beliefs sometimes go too far.

A mother-in-law was sometimes willing to risk the health and safety of her daughter-in-law and her grandchild for the sake of traditional and cultural beliefs and there could be delay in seeking health care due to beliefs in witchcraft and traditional healers in some families:
“The cultural beliefs goes ahead of safety, that will directly and indirectly affect the woman’s health. The grandmothers that are handling the neonate and they think this is, and are willing to risk the health” (informant 10). 

“Mostly they come from very traditional family and they go through witchcraft and traditional healer and if they could not get rid from that then they just go to the local health facility levels” (informant 11). 

The healthcare providers’ described how women were forced by cultural norms to work hard and take care of themselves and the baby without complaining, no matter what the condition. This even applied the day after delivery in the rural areas: 
“They have heavy workload; they are forced to work until delivery and start the day after” (informant 4).
 
Women’s value and consideration are low 
Women’s decision-making and sexual and reproductive health and rights was of less concern for a family because of a woman’s low value. In large families, women’s and girls’ decision-making authority and concerns were considered, by the healthcare providers, to be more neglected than in small families. In small families with one or two children, they could afford schooling and health care for girls and women. In large families, boys were prioritised; hence family structure had a great impact on women’s and girls’ human rights: 
“In the traditional joint family, there were more and more work to the woman. Her responsibility is to take care of children and household also. When there is a large family, she will not eat properly because in Nepalese culture, the woman should take the last of meals” (informant 10).

Women were sometimes, according to the healthcare providers, afraid of being physically abused by their husbands or mothers-in-law if they delivered more than one girl.

Furthermore, a family might not give the woman or the baby girl care as good as if she had delivered a baby boy:
“The girl and woman does not get care, the family start scolding, refuse the food, they don’t take care of the woman or (female) child” (informant 11). 

Sometimes this lack of caring for women who give birth to a baby girl in turn makes the woman unable to care for the girl. When a woman delivered a boy, she could rest for 45 days, but not if she had a girl: 
“If she gives birth to a boy then she can get rest for 45 days, if she delivers a girl, she has to work from next day. If she delivers a girl, she doesn’t get varieties of food” (informant 11).

Even if a family was educated and economically strong, they still considered girls to have low value and preferred a boy that would grow to be a man who would be able to earn money and take care of generations to come. The girl would be given away to her husband’s family when she married and they did not always care for their daughter-in-law. 

“They (in-laws) were saying ‘no, we don’t care about the health of the daughter-in-law, we just need a boy. If she dies or lives, it doesn’t matter’” (informant 12).

Traditional family structure – a support for women’s decision-making authority 
This category, comprised three sub-categories: ‘Women’s age and education gives decision-making authority’, ‘Women strengthened by her family make own decisions’, ‘In good relations women are listened to before final decision’.

Women’s age and education gives decision-making authority
Healthcare providers’ perceptions were that women were listened to and their situation in the family improved with age and education. When a woman got older and eventually became a mother-in-law herself, she could give her daughter-in-law advice according to her own experience and beliefs. She got authority and her son/sons would listen to her:
“Elderly (women) are more powerful” (informant 13). 

Women strengthened by her family make own decisions 
The healthcare providers’ perceptions were that these days in-laws encouraged women to make their own decisions about their sexual and reproductive health and rights. In some families, women got help and support during and after childbirth by their husband and their mother-in-law, who encouraged them to make their own decisions about  antenatal care and where they wanted to give birth: 
“Nowadays they (in-laws) encourage health care. Nowadays they (the in-laws) are very good. Even in rural area, they (the women) come” (informant 4).

In good relations women are listened to before final decision 
The healthcare providers’ perceptions were that the family structure in both single and joint families had an impact on women’s decision-making authority in a pixelated way. The woman’s situation depended on the relationship with her husband and the family. The relationship with in-laws was sometimes troublesome if the woman earned money and was supported by her husband to make her own decisions:  
“Mother-in-law helps and teaches housework also. Relations are good. They (the daughters-in-law) cannot decide for themselves, it is first the husband and the mother-in-law, then father-in-law and the sisters…” (informant 13).

Discussion

The major findings of this study were that the healthcare workers perceived that patriarchal traditional family structure had great impact on women’s decision-making authority. It could be both a barrier and support for women’s sexual and reproductive health.

In this study, when the patriarchal family structure was described according to perceptions of healthcare workers, a barrier of the women’s decision-making authority was considered very limited and reduced. Decisions in the extended, patriarchal traditional family were mainly made by the head of the family – the father-in-law. Regarding women’s or children’s health, decisions were usually made by the mother- or sister-in-law or the husband. This was believed to be even more common in conservative families and in some of the poorer and less developed parts of the country, where home births were more common. Nevertheless, the patriarchal family structure was also described as being supportive. Mullany et al (2005) questioned if women’s autonomy could impede male involvement in pregnancy health in Nepal. The question indicates the cultural complexity of a society (Bronfenbrenner, 1977) and that there are seldom simple solutions.  

International and national agencies agree that access to education and modern technology will change the future for youth, particularly in rural areas. Hopefully it will promote gender equality and empowerment of women, including in the area of SRHR (Mattebo et al, 2015; WHO, 2015; UNFPA, 2014; WHO, 2014; Khatiwada et al, 2013;  Kaufman et al, 2012).  

The findings of this study are supported by research showing that some women were empowered by their own education and the family’s educational level (Williams et al, 2014; Acharya et al, 2005). These women were often allowed to make decisions for themselves and their children regarding health care, but the impact of tradition was still very strong, even in well-educated families. This shows that traditions have a strong impact on families, regardless of education. Girls and women are, according to UNFPA, often discriminated by culture in a patriarchal society (UNFPA, 2014). In the population-level based study from five countries (Namasivayam et al, 2012), the patriarchal family structures restrict women’s ability to decide for themselves about family planning, pregnancy and antenatal care. In turn, this restriction affects both a woman’s health and that of her children (Dhakal et al, 2013; MoPH, 2012). This study showed that healthcare practitioners believe there is an ongoing change in the Nepalese society. Modern families are moving to cities for work and education and some strong traditions are fading out. A range of cultural perspectives will change (Bronfenbrenner, 1997), and this will hopefully promote gender equality and the empowerment of women in the future. However, the recent earthquake shows how fragile predictions for the future are (Simkhada et al, 2015); the most vulnerable in society will be affected the most – and that is most often women and children. 

The healthcare workers interviewed suggested that in the patriarchal traditional family structure the woman’s health was not considered particularly important and the family was more concerned about the birth of a male heir. This was in line with findings in the study by Clarke et al (2014). The results showed that there was a correlation between women’s psychological health and distress as a consequence of the gender and social disadvantage for women in rural Nepal Clarke et al (2014). 

Healthcare providers need to be aware of the social disadvantage experienced by some women and address, involve and cooperate with all family members, when necessary, in order to be able to offer the women vital health care. This requires a self awareness in healthcare providers of how culture affects one’s own perspective on women’s reproductive decision-making. A theoretical framework, such as the Ecological System Theory (Bronfenbrenner, 1977), can help when reflecting on the multidimensional and interlinked perspectives.  

Findings of this study indicated that sexual and reproductive health was not an open topic in Nepali society. According to the healthcare providers, women’s groups have been started in many communities by healthcare providers. The groups are led by women chosen by the community who were then educated when the healthcare services and they then transferred information to their own village and community. This can be related to the study by Thapa and Niehof (2013), where the importance of women’s autonomy and of men being involved in the maternal care was highlighted. The researchers found that programmes for improvement of the woman’s autonomy and, at the same time, an increase of the husband’s involvement should be planned carefully. 

The study also showed that Nepalese men were becoming more involved in maternal health. Hence, there is an incentive to involve both women and men in reproductive life planning. The ‘men for women’ approach in Nepal might be a way forward to promoting gender equality and the empowerment of women (Mattebo et al, 2016). The recent earthquake might have hampered the short-term decrease of MMR and NMR in Nepal and the entire context of sexual and reproductive health; however, in the long term, there is a possibility that the MMR and NMR will continue to decrease since awareness of factors in society affecting women’s sexual and reproductive health and rights is rising among Nepali women themselves, as well as the men and families.

Limitations

Data collection was conducted from November 2014 to January 2015. A main limitation of the study was the relatively small numbers of interviewees. However, credibility was strengthened by the diversity of the participants’ experience levels, ages, educational levels and origin from different geographical areas of Nepal, both rural and urban. This gave a rich description of the studied field and made the findings, after consideration, transferable to other relevant settings (Polit and Beck, 2012). 

An inductive approach has been utilised for the analysis of this data. A deductive approach utilising a conceptual framework, such as Bronfenbrenner’s (1977) theory, might have added value to this study. Utilisation of a conceptual framework might have better acknowledged the interwoven/interlinked nature of the participants’ perceptions. It could always be discussed how snowball sampling with participants, who want to share their view of the topic, would affect the trustworthiness and transferability of the results (Polit and Beck, 2012). 

A strength and a limitation of the study might have been the fact that the interviewer (ML) was not from the country and, although still familiar with the culture, lacked native language skills. To avoid the need for translation, and thus possible misinterpretations from Nepali to English, one of the inclusion criteria to participate in the study was knowledge of English to the extent that it was possible to carry out an interview. This was considered to increase the credibility of the study, since no translations and back translations were necessary (Abujilban et al, 2012). 

There are some potential implications of conducting the interviews in English in that some cultural nuances could be misinterpreted or otherwise lost. In Nepal the informants are often more willing to talk if someone, such as a relative or colleague, was there to oversee what was being discussed. How to select informants and deal with individual interviews as a data-gathering method in cultural context other than one’s own, needs to be discussed in a culturally-sensitive way. The rationale for not including vulnerable women themselves rather than health workers in Nepal was due to the aim of the study and the advice from the ethical board.  

Conclusion

This study highlighted the influence of culture, traditions and society on women’s decision-making authority in a patriarchal culture. The family structure was perceived as both a support and a barrier to women’s sexual and reproductive health. The study showed that there is an ongoing change in Nepalese society. Modern families are moving to cities for work and education and some strong traditions are fading out.  

Clinical implication

Insights into the influence of a patriarchal culture on women’s reproductive decision-making can, for healthcare providers and development workers, bring about an understanding of the complexity in society. The study can be used for reflections on why international and national reproductive healthcare policies promoting gender equality, empowering women and provision takes time to implement because of a range of cultural perspectives. A deductive approach utilising a conceptual framework is suggested for further studies to better understand the Nepali culture.

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References

Abujilban S, Sinclair M, Kernohan WG. (2012) The translation of the childbirth self-efficacy inventory into Arabic. Evidence Based Midwifery 10(2): 45-9.

Acharya S, Yoshino E, Jimba M, Wakai S. (2005) Empowering rural women through a community development approach in Nepal. Oxford University Press and Community Development Journal 42(1): 34-46.

Bajracharya A, Amin S. (2012) Poverty, marriage timing, and transitions to adulthood in Nepal. Studies in Family Planning 43(2): 79-92.

Baral YR, Lyons K, Skinner J, van Tejlingen ER. (2010) Determinants of skilled birth attendants for delivery in Nepal. Kathmandu University Medical Journal 8(3): 325-32.

Bronfenbrenner U. (1977) Toward an experimental ecology of human development. American Psychological Association 32(7): 513-31. 

Clarke K, Saville N, Bhandari B, Giri K, Ghising M, Jha M, Jha S, Magar J, Roy R, Shrestha B, Thakur B, Tiwari R, Costello A, Manandhar D, King M, Osrin D, Prost A. (2014) Understanding psychological distress among mothers in rural Nepal: a qualitative grounded theory exploration. BMC Psychiatry 14: 60.

Devkota B, van Teijlingen ER. (2010) Understanding effects of armed conflict on health outcomes: the case of Nepal. Conflict and Health 1(4): 20.

Dhakal S, van Teijlingen ER, Stephans J, Dhakal KB, Simkhada P, Raja EA,  Chapman NG. (2013) Antenatal care among women in rural Nepal. Online Journal of Rural Nursing and Health Care 11(2): 76-87.

Elo S, Kyngäs H. (2008) The qualitative content analysis process. Journal of Advanced Nursing 62(1): 107-15.

Ensor T. (2009) What drives the health policy foundation: insights from the Nepal incentive scheme. Journal of Health Policy 90(2-3): 247-53.

Hatamleh R, Sinclair M, Kernohan G, Bunting B. (2008) Technological childbirth in northern Jordan: descriptive findings from a prospective cohort study. Evidence Based Midwifery 6(4): 130-5.

Kaufman M, Harman J, Shrestha D. (2012) Let’s talk about sex: development of a sexual health program for Nepali women. Education and Prevention 24(4): 327-38. 

Khatiwada N, Silwal PR, Bhadra R, Tamang T. (2013) Sexual and reproductive health of adolescents and youth in Nepal: trends and determinants – further analysis of the 2011 Nepal demographic and health survey. See: dhsprogram.com/pubs/pdf/FA76/FA76.pdf (accessed 12 September 2016).

Mattebo M, Elfstrand R, Karlsson U, Erlandsson K. (2015) Knowledge and perceptions regarding sexual and reproductive health among high school students in Kathmandu, Nepal. Journal of Asian Midwives 2(2): 21-35.

Mattebo M, Sharma B, Dahlqvist E, Molinder E, Erlandsson K. (2016)Perceptions of the role of the man in family planning, during pregnancy and childbirth: a qualitative study with 15 Nepali men. Journal of Asian Midwives 3(1): 31-45. 

Ministry of Health and Population. (2012) Nepal: demographic and health survey 2011. See: http://dhsprogram.com/pubs/pdf/FR257/FR257%5B13April2012%5D.pdf (accessed 12 September 2016).

Mullany BC, Hindin MJ, Becker S. (2005) Can women’s autonomy impede male involvement in pregnancy health in Kathmandu, Nepal? Social Science & Medicine 61(9): 1993-2006.

Namasivayam A, Osuorah DC, Syed R, Antai D. (2012) The role of gender inequities in women’s access to reproductive health care: a population-level study of Namibia, Kenya, Nepal, and India. International Journal of Women’s Health 4: 351-64.

Paudel R, Upadhyaya T, Pahari D. (2012) People’s perspective on access to healthcare services in a rural district of Nepal. Journal of Nepal Medical Association 52(185): 20-4.

Polit M, Beck CT. (2012) Nursing research: generating and assessing evidence for nursing practice. Lippincott Williams and Wilkins: Philadelphia.

Regmi K, Smart R, Kottler J. (2010) Understanding gender and power dynamics within the family: a qualitative study of Nepali women’s experience. The Australian and New Zealand Journal of Family Therapy 31(29): 191-201.

Rocca C, Puri M, Dulal B, Bajracharya L, Harper C, Blum M, Henderson J. (2013) Unsafe abortion after legalisation in Nepal: a cross-sectional study of women presenting to hospitals. BJOG 120(9): 1075-83. 

Simkhada P, van Teijlingen E, Puspa RP, Brijesh S, Gangalal T. (2015) Public health, prevention and health promotion in post-earthquake Nepal. Nepal Journal of Epidemiology 5(2): 462-64. 

Thapa DK, Niehof A. (2013) Women’s autonomy and husband’s involvement in maternal health care in Nepal. Social Science & Medicine 93: 1-10.

UNFPA. (2014) UNFPA puts young people in the picture through selfies. See: un.org.np/headlines/press-release-unfpa-puts-young-people-picture-through-selfies (accessed 12 September 2016).

Williams NE, Thornton A, Young-De Marco LC. (2014) Migrant values and beliefs: how are they different and how do they change? Journal of Ethnic and Migration Studies 40(5): 796-813. 

WHO. (2015) Global health observatory country views: Nepal statistics summary (2002-present). See: http://apps.who.int/gho/data/node.country.country-NPL (accessed 12 September 2016).

WHO. (2014) Success factors for women’s and children’s health. See: who.int/pmnch/knowledge/publications/nepal_country_report.pdf (accessed 12 September 2016).

World Medical Association. (2015) WWA Declaration of Helsinki – ethical principles for medical research involving human subjects. See: wma.net/en/30publications/10policies/b3 (accessed 12 September 2016).