Two-year-old Rajkala was the first child born inside her parent's house, instead of a cowshed. Photos by Alina Labrada © CARE 2001.

"Lucky" Rajkala was born inside her family's home, and this time her mother had clean tools and an attendant present with the know-how to help with a safe delivery. This evolution in experience is illustrative of the benefits that a CARE family health project is bringing to isolated communities in western Nepal.

In Bajura, where Rajkala's parents Sauni Bishwokarma and Vashi Shahani live, certain Hindu beliefs -- particularly ritual pollution beliefs influencing childbirth practices -- are interpreted differently. Women are considered unclean when they are giving birth and must stay in a place apart from the rest of the family for between 11 to 28 days after the baby is born. In Bajura, traditionally this place is the chhau gar; the cowshed attached to the house. The mother cuts and ties the umbilical cord herself, often with a sickle still dirty from farm work. Nepal has one of the world's highest maternal mortality rates because of the unsanitary conditions during labor. More than 500 women die for every 100,000 live births.

Sauni Bishwokarma gave birth safely to Rajkala, after losing a son in childbirth.

But since 1992, CARE has been working hard to make motherhood safer in Bajura. The organization works in five districts in the area, providing family health classes, safe- delivery kits and training for birthing attendants. The village family health classes, emphasizing the importance of sanitary conditions for childbirth, are provided for both men and women. The project is reaching 170,000 people.

Sauni and Vashi live in Kolti, one of more than 50 villages in the area. And during her pregnancy with Rajkala, Sauni and Vashi attended these classes.

Vashi Shahani and Min Raj Gyawali, a CARE health supervisor.

"The classes were very useful," Vashi says. "I want my wife and children to survive and be healthy. That is the most important thing. I bought a safe-delivery kit and Sauni used it to give birth inside the house," says Vashi.

CARE encourages families to use the safe-delivery kits that consist of a sheet of plastic, a bar of soap, a razor blade, a cutting surface, a string and instructions. Made by a Nepali company, CARE supplies the kits for free to traditional birth attendants and mothers' groups. The attendants and the groups then sell the kits to members of their communities for 20 rupees, or about 27 cents.

Even at this low price, very few people in poverty-stricken Nepal can afford the kits. So CARE also is teaching women to use a clean blade to cut the umbilical cord instead of a sickle and to use clean thread to tie the cord, as an option to the kit.

Premkala Khatri is one of several hundred women in Bajura who have been trained by CARE as birth attendants.

CARE has found educating prospective mothers about safe delivery practices to be of critical importance. Women in Bajura usually bear their children alone. No one can touch either the mother or the newborn for fear of becoming unclean by association. If they touch the mother, they too must observe the 11- to 28-day period of separation.

Traditional faith healers, when they are called to attend a birth, come no closer to the mother than the doorway of the animal shed. They are afraid to touch the mother during a difficult birth. Sauni explains that this is what happened with her first-born son.

"He was twisted around inside me. It was very painful. The birth attendant did not put out her hand to me to help," says Sauni.

"The traditional healers fear the gods," explains Gopal Shrestha, CARE's project manager in Bajura. "They say the gods will be offended if they touch a woman in labor. They say they will become unclean themselves and the gods will punish them."

Spreading knowledge about safe motherhood.

Bajura is a difficult place to eke out a living. Less than 6 percent of the land is arable, and most of it is not irrigated. Even the people who are supposedly well-off are not able to grow enough food to last longer than six months a year. No one is eager to incur the wrath of the gods.

Family tradition also extends a powerful influence on birthing practices. Extended families are common and mothers-in-law often dominate the household. Many times it is the mother-in-law who insists on upholding the custom of ritual separation.

"It is a cultural custom and they see no reason to change a practice that has been handed down for generations," says Shrestha. "The men in the house see no reason to go against tradition either. For this reason, CARE now includes men in the same training we give to women. In this way, we are making men more aware of the health risks associated with this cultural practice and slowly modifying behavior to promote safe deliveries and healthy babies and mothers."

"Less than 1 percent of the births were attended before we began working in Bajura," says Robin Needham, CARE's country director in Nepal. "Now between 40 and 50 percent of births are attended by trained healers or attendants."

Sauni called on Premkala Khatri, one of these attendants, when she was going into labor with Rajkala.

"My mother was a traditional midwife and I learned from her. Then I learned from CARE. I don't hesitate to touch [patients] because it's more important to save lives. My mother is proud of me for practicing new, safer ways to deliver babies," says Khatri.

"After CARE's teaching and training, I think people's attitudes in the village began to change. People respect me and my work."

Cows are no longer the only witnesses to a birth. Between 40 and 50 percent of women in Bajura are now calling on CARE-trained birth attendants to help deliver their children.

"This delivery was better. Premkala helped me and there was less pain," said Sauni.

Shrestha reports that "while more than 80 percent of the women in the project area still give birth in the cowshed, more and more women are cleaning the cowshed first, as CARE taught them. We are making progress."

Though Needham cautions that "changes will take a generation or two," in Rajkala's household, it seems to already have taken hold.

Rajkala's mother, Sauni, is pregnant again. Her husband, Vashi says: "We will do the same this time as the last. Sauni will have the baby inside, using the kit. We will call a trained birth attendant."

Standing outside her family's cowshed, Sauni holds Rajkala in her arms. "She won't have her babies here," she says, indicating the shed. "This place is only for the animals."