Posted by Dr. Susan Warren
“Bayalpata drowns in the tears of its women.”
- unknown Achhami poet, quoted by clinician
“A woman might get married at age 12. She gets pregnant right away and hopes for a son. The women work hard and the husband is away most of the time for jobs. He spends too much money on drinking. The women are dissatisfied and it causes turmoil in the family. If a woman is mentally dissatisfied, the child may not be healthy.”
- conversation with clinician at Bayalpata Hospital
In developing countries, two key determinants of women’s health—gender disadvantage and reproductive health—are associated with a higher risk for depression and anxiety. Gender disadvantage includes: severe economic difficulties such as hunger, minimal influence in decisionmaking, low family support, marital sexual violence, being widowed or separated, and reproductive health factors. (1) In a 2009 report by the World Health Organization, the “lack of consideration of mental health as a determinant of reproductive mortality and morbidity especially in the developing regions of the world” was strongly stated as a failure to understand the crucial influence of mental health on reproductive health. (2)
At Bayalpata Hospital, clinicians and staff members know about the problems of women in the community. During a recent visit to the hospital, Nyaya Health U.S. team members spoke with the Nepali staff about the psychosocial problems they observed.
The most worrisome concerns for women were identified as:
- alcohol abuse among men
- failure to produce a son
- early marriage.
Although Achham is a dry district, alcoholism was repeatedly mentioned as a major problem. The staff did not comment extensively on domestic violence, but other observers have linked alcohol abuse with assaultive behavior by men. Women also resented the money lost for alcohol.
Poverty, lack of education, lack of income-producing skills, inadequate food, illness during pregnancy and positive HIV status were among the most significant problems. Details of social and economic adversity colored every conversation. Although the content and tone suggested it, anger was not mentioned directly in any discussions. We did not, however, ask specifically about the role of anger in the emotional lives of the women, or the societal norms related to expressing it.
The practice of chhaupadi and uterine prolapse were mentioned as important but often unexpressed problems for women. Trafficking of women from the district of Achham was not common, and not a concern.
The symptoms typically associated with a depressive disorder such as sadness, poor sleep, hopelessness, lack of enjoyment or suicidal feelings were not considered prevalent among the women. The impression among staff that women were not experiencing high rates of suicidality is of interest in light of the recent Nepal 2008/2009 Maternal Mortality and Morbidity Study which reported the unexpected finding that suicide is the leading cause of death in women aged 15-49.
In India, in one study (3) of women aged 18-50 who attempted suicide, the authors concluded that among women in developing countries, social and economic factors including exposure to violence, physical illness, social exclusion and economic hardship may be stronger predictors of suicide attempts than mental illness. They commented that it was not surprising that suicide is one of the leading causes of death among young women in Asia given the availability of highly lethal methods such as pesticides combined with limited access to emergency care.
In discussing the impact of the ten-year armed conflict, the staff thought that many people felt “caught in the middle” between government forces and the Maoists. Fears for safety and the unrelenting demands for food and money dominated their lives. They saw no positive changes as a result of the war, except for some increase in assertiveness among women and lower caste members. The psychological aftermath of the war is not known, but Achhamis suffered widespread violence in their villages.
Positive aspects of women’s lives were identified as:
- Giving birth to a male child
- Food grown from their field
- The return of their husband from [working in] India
- Social support: families live in clusters and are there for each other
Husbands were the main source of help for most women, despite the apparent frustration with aspects of the marital relationships. During childbirth, women turned to female relatives.
Solutions to the problems were:
- love and affection in the household; equality in marriage
- education
- programs for income generation.
Where “sons are as income, daughters as expenses,” respect, education and financial well-being were seen as the means to improve the lives of disadvantaged women. In these conversations, women were seen as suffering, and the solution to their “mental dissatisfaction” is the fulfillment of basic human needs. The Women’s Center at Bayalpata Hospital is dedicated to women’s health. The Center will continue to develop resources, over time, to address the underlying social and economic inequities that profoundly influence physical and emotional health.
References
1. Patel V, Kirkwood BR, Pednekar,S et al. Gender disadvantage and reproductive health risk factors for common mental disorders in women. Archives of General Psychiatry 2006;63:404-413.
2. World Health Organization. Mental health aspects of women’s reproductive health: a global review of the literature. Geneva: World Health Organization, 2009.
3. Maselko J, Patel V. Why women commit suicide: the role of mental illness and social disadvantage in a community cohort in India. Journal of Epidemiology and Community Health 2008; 62:817-822.
Susan Warren, M.D. is a psychiatrist in Boston, Massachusetts. She is a volunteer with Nyaya Health in the development of The Women’s Center at Bayalpata Hospital, funded by the Ella Lyman Cabot Trust. She visited Bayalpata Hospital in October, 2009 to learn about women’s health from the clinicians and staff at the hospital. This report is a summary of those thoughtful and generous conversations. Dr. Warren is a member of the Department of Psychiatry at Massachusetts General Hospital and a Clinical Instructor at Harvard Medical School.
Good post and nice design, is this a regular template?
[...] been neglected both in the developed and developing world. In Nyaya’s own work, mental health disease has been extremely difficult to address given limited human resources or public health [...]