Krishna Kumari Pun

To end women’s isolation during labor, delivery, and the early post-partum period that leads to high maternal and infant mortality rates in Nepal, Krishna Kumari Pun has built a health care system based on women’s commitment to each other. Krishna’s holistic health care system and social change structures will not only raise the status of women in Nepal but will translate into increased economic and social development in Nepal.

Krishna has developed an integrated system of health care through her organization, Snehi Jagaran Mahila, to ensure the health of women and children. This system provides women with training and skills to care for themselves and other women during pregnancy and works to end a cultural system of isolation prevalent in remote districts throughout Nepal. It ensures care for the mother’s health during pregnancy and the baby’s safe delivery. Krishna is to dispelling stigmas of female “pollution” during pregnancy through education and midwifery training. Snehi Jagaran Mahila provides female village leaders with maternity service training. Following their training, they are charged with providing midwifery services to villagers in need. Krishna has trained enough women to have a midwife present in every Village Development Committee in Baitadi, in the far west region of Nepal. These local midwives services include monthly check-ups, birthing services, and care after childbirth; free of charge if necessary. Collectively, these women demonstrate that childbirth and menstruation do not pollute women, but ensure that women have safe pregnancies and deliver healthy babies. In addition to transforming the experience of birthing and motherhood in Nepal, Krishna is changing the perception of a woman’s place in society—pregnant mothers now receive adequate health attention. Krishna believes it takes collective action to dispel stigmas surrounding women’s reproductive health. If women work collectively to promote safe birthing practices and raise awareness, the stigmas associated with birth will cease to exist. To this end, Krishna pursues a unique, holistic approach, combining access to health care before, during, and after childbirth, with other empowering social structures. Krishna also established a maternity center/hospital in Baitadi—one of the most isolated and poorest districts in the country—where village women receive delivery assistance, counseling, and general health services, at minimal cost. The revenue for maternal care is subsidized by paid-for-care given at the dental health clinic, the pharmacy, and the family planning unit, in Krishna’s village hospital. Currently, Krishna is focused on training health staff, establishing an active maternal health network among villages, and expanding to other districts.

Health care has not been a national priority in Nepal, especially for women, perhaps because Nepal remains a feudal and patriarchal society. In Nepal, women do not deliver in formal health facilities because they are few and far; perhaps a two to five days’ walk. Local midwifery or physician services are not available. Village women menstruate and deliver their children in isolation and unhygienic conditions like cowsheds—following the traditions of the Chaupadi system—as women are viewed as unclean and impure during these times. Even when a woman’s labor is not progressing or when she is experiencing bleeding or postpartum infection, she will not be touched by anyone, including family members. Her status as a ‘polluted’ person continues for eleven days after delivering a child. Therefore, often postpartum complications lead to the deaths of many rural village women and babies. Statistically, every two hours, a (usually) young Nepalese woman dies giving birth. Maternal mortality in Nepal is one of the highest in the world. In 2005, the reported infant mortality rate was 64 per 1,000 live births. In the past ten years, 45,000 Nepali women have died due to complications during childbirth. Maternal and infant mortality are among the most preventable causes of death in the world today; yet, in Nepal, twelve women a day die during childbirth.In most rural areas of Nepal, pregnant women are forced to carry heavy loads and to work long hours in the fields. There are no hospitals or health posts nearby and they have to rely on traditional birth attendees, local shamans called dhami and jakris, or family members for care during pregnancy. Illiteracy, poor maternal nutrition and health, very short birth intervals, and inaccessibility to health care facilities, contributes to high levels of maternal and neonatal mortality. Since pregnant women are not always properly fed and cared for, the risk is higher. Early marriage, unsafe abortion, unsafe delivery, and postnatal complications also contribute to many deaths. Many young girls married at ten to fourteen years of age do not understand how their bodies work or what to expect during birthing. Although there have been improvements in health infrastructure by international and domestic citizen organizations (COs) and the Government, much work needs to be done. Family planning services have been expanded in the last decade, but there are stark inequalities in services between rural and urban areas. The far west is completely isolated from the rest of Nepal in terms of development services; the institutions of health and education are weak. According to a study conducted by the National Institute for Health, approximately 90 percent of births occur at home in unhygienic and septic conditions. Trained health workers assist only 13 percent of deliveries in the country and more than 67 percent of maternal deaths occur at home; most occurring in remote areas of the country. Extreme poverty, illiteracy, ignorance, no access to roads, a lack of transportation, a lack of trained health personnel, limited emergency services, and rigid social and cultural practices, aggravates the situation.Due to the proximity to India and the common border that India and Nepal share, if money and time are available, many women in the Terai (the southern agriculture region of Nepal) go to India. However, poverty is rampant in the far-western region of the country, and unsafe abortions and deliveries continue due to insufficient resources for proper care in India.

Krishna has created an environment conducive to healthy motherhood through Snehi Mahila Jagaran Kendra. Snehi Mahila Jagaran Kendra offers counseling, training, and health awareness, to rural village women. A trained nurse, Krishna was determined to end dangerous and unjust traditional practices and care for women’s physical needs. She quickly realized one cannot focus on only one phase of a woman’s life, such as childbirth. She developed a four-part sequenced model to improve the women’s status: 1) literacy with a health component 2) savings and credit groups with set asides for health emergencies 3) paraprofessional health skills development, and 4) access to local and district services. Krishna begins with literacy classes for village women with a special focus on reading about basic health. During literacy education, women read about good health and nutrition. Next, savings groups (which she initiated before hearing the term “microfinance”) with a health component woven into this economic tool. A primary component of Krishna’s microfinance scheme makes it mandatory for a portion of a woman’s earnings to be set aside for health emergencies. In addition, part of the membership requirement to join a savings group is signing a commitment that no woman in your family or village will ever again deliver a child in isolation or in an unclean environment. Next, new health services provided locally within villages by trained paraprofessionals that have been selected from savings groups. Finally, advocating for formal maternity centers/hospitals to be operated by the government. Women are grouped as they progress and are encouraged to form savings and credit groups with twenty to forty-five members. These groups save money, receive training on income generation opportunities, take credit, and set aside a certain amount for members with emergency complications during labor or delivery. The support groups also pressure family members to end socially unjust practices toward women; to lift restrictions and cultural norms that hinder women from full economic, health, and social participation. Skills development varies in each village depending on the available resources, for example, agriculture, milk selling and processing, goat and pig rearing, and textile weaving on handlooms. Economic resources give village women choice and voice.Krishna’s staff (women emerging from the literacy and savings groups) spread to new villages and also work through COs and volunteer associations to inspire and organize others to form groups. Two women from each group are given training as Auxiliary Nurse Midwives (ANMs) and later they can give direct care while also training other midwives. Krishna has formed thirty-nine groups with seven-six trained ANMs. They are prepared to perform safe deliveries and disseminate information on family health and nutrition. They conduct campaigns to reach the general public to stop harmful social practices that discriminate against women, especially during childbirth. If the ANM’s want further training as nurses, the government will provide food and lodging for them during their studies, while the savings and credit groups provide a stipend, from the pool of savings set-aside by the credit groups. This further binds the groups and ensures a pipeline of new professionals with common values.. Krishna includes the whole community in her program, holding it and the families responsible when women are isolated during birthing. It is a holistic and integrated approach. She has constructed clear rules for members of the health groups. Once they participate in the training, they must fully support pregnant women. The members of credit groups are required to sign forms stating that no woman will deliver in a cowshed, and once labor begins, the family members at home and the neighbors must do all they can to support a woman to safe delivery. Surprisingly, this practice has eased the often strained relationships between mothers and daughter-in-laws and has led to greater social harmony. Advocacy groups that have been created also work to lower alcohol consumption among men.The parallel health system Krishna has built prepares the two trained village women from each group in health advocacy and to lobby to access government funds for vaccinations and other primary health care. Their goal is healthy mothers and healthy families. The mothers who use the government hospitals in emergencies or with their regular savings are entering the system for the first time as paying customers. Paying customers can demand better service, so this will serve to regulate and improve the government health system.Realizing that small and preventable problems can lead to death of pregnant mothers and new born babies, Krishna has been careful to create prenatal and postpartum health facilities and programs that are simple and appropriate. They can be implemented by semi professionals and rural health care workers who emerge from her trainings. Each Snehi Mahila Jagaran Kendra has three rooms—one for family planning, a maternity room, and a dental clinic. Five percent of the clinic fees go back into the organization to administer and expand the program for women’s awareness on health and safe delivery. Krishna has designed different courses for different women. Those who are illiterate are given basic knowledge and awareness on hygiene and safe delivery practices, with flip charts, stories, examples, and street theatre. The semi-literate are provided with ANM trainings. Krishna has started awareness programs in schools, since most of the girls are married when they are very young and have no knowledge of their own anatomy or basic health care. Mobile camps have also been conducted to give village women general knowledge on safe motherhood, delivery, and postnatal care.Krishna’s outstanding health care facilities for safe motherhood are gaining attention. She has been asked by other women’s groups in neighboring districts to replicate her model.

From an early age, Krishna longed to become a health care professional. When she was eleven, her older brother was hospitalized. She was deeply impressed by the tender care her brother received from the nurses and doctors while he was hospitalized. She told her brother she wanted to become a nurse and he promised that if he survived, he would make sure she could continue her schooling. One month later he died, but her dream continued. At fourteen, however, Krishna was married and a year later was pregnant with her first child. Bound by the Chaupadi system, Krishna was sent to the jungle to deliver alone. During delivery, her baby died. Krishna vowed that this should not happen to other woman and is committed to abolishing this practice.Krishna begged her husband to allow her to attend school, but within Nepal’s conservative patriarchal system, her hopes for higher education were at first denied. Her husband refused, but despite this, Krishna continued to seek access to knowledge. Secretly, she convinced a friend to share her notes from class. Krisha’s uncle helped her too. She studied independently and then took the exams when she was ready. Remarkably, she obtained an education up to class 7.One day, she saw an advertisement for class 9 students seeking sixteen people interested in health care. Krishna wanted to seize this chance but her mother refused her plea to apply saying hospital work was only for lower caste people, and if she were to join work at the hospital, the water she touched would no longer be acceptable to others (Krishna is from a lower caste family). Despite her mother’s warnings and a second pregnancy, Krishna applied for the position. Following her interview, she was posted first of the sixteen. Still studying in secret, she sold her gold marriage necklace to pay her fees.Once a full-fledged nurse, Krishna joined the Shining Hospital—a leprosy hospital—in Pokhara, where she worked for fourteen years. She came to feel that there must be a way to ensure that everyone could access health facilities and that no one would be left behind. She left her secure job and moved her family back to her home town. She soon gained credibility with the local villagers when she saved the life of a mother and her baby during a difficult delivery—the women had lost seven previous babies. With the knowledge and confidence Krishna gained, she set out to change the experience of womanhood and motherhood in Nepal.