DOTI - March 2001. I am in Doti district, one of the most remote areas of Nepal, about 700 km west of the capital. I am coordinating a health programme organised by GTZ, the German international development organisation. We are running a special gynaecological camp in the Doti district hospital, designed especially for women of the far-western region .

A woman is brought in. Her brother carried her to the hospital, and her mother and two small children accompany them. Her name is Kamala. The family reports that seven days ago, Kamala had a spontaneous abortion. She has been bleeding continuously since then. Kamala is pale as a sheet. She cannot even open her eyes.

A senior gynaecologist examines her and says, "She has lost a lot of blood and has an infection. We need to transfuse blood immediately, but it is not possible here. It would be best if we send her to another hospital where transfusion facilities are available." We research the cost of an ambulance and discover it will be around Rs 1,700. We discuss this with Kamala's brother and mother. They answer, "We do not have money to take her to the hospital. If you can treat her here, please do so. Otherwise, she will die here and we will not blame anyone."
We doctors talk among ourselves and decide that we will collect the money and hire an ambulance to take her to the closest hospital-a seven-hour drive away. But after assessing the patient's condition again, the gynaecologist, DrVeena Rani Shriwastav says, "Even if we could arrange the money and ambulance, it is not advisable to send her to Dhangadi hospital as she is really in very serious condition. It would be better if we could do the surgery right away."

So Kamala does not go to Dhangadi Hospital. She is not operated on that night either, as the lights in the hospital are out. We pray that she survives the night. In the morning, we are happy to see that she is still alive. Dr Shriwastav says, "Now I will operate on her. I know it is a risk, but if all of you support me, I am ready to take the risk."

Time passes. At ten in the morning, I asked Dr Shriwastav about Kamala's condition. She replies, sounding very sad: "I have not operated on her because her mother did not allow me." I was surprised and angry.

I go to find Kamala's mother; she is feeding her two grandchildren rice and salt. I ask her, in a mixture of local dialect and Nepali, "Why did not you allow the doctor to operate on Kamala?" The old woman looks at me with sad eyes and starts crying. "I do not know what to do," she says, "Kamala's husband is not here. She has five girls and only one son. If you will operate, you will take out her uterus and she will have no more children. Her husband will be very angry with me and will leave Kamala."

I am confused. I wonder why she needs more children, after six. Then, with a shudder, I understand what this woman means. She is saying "children," but she does not mean children, she means sons. How pathetic it is to hear such logic! The old woman was more worried about an unborn grandson than life of her own daughter. I collect myself and explain to her that we will not take out the uterus and that after she heals, Kamala can have as many children as she wants.
Then, local health workers explain to the family the surgery in their local dialect. Finally, the mother is convinced that her daughter will be able to bear more children (sons). She says, "Do as you like, but please save my girl." Within half-an-hour, Kamala is undergoing the surgery she needs. Though very weak, she is finally out of danger and we are happy. We congratulate Dr Shriwastav, who took a great risk to save Kamala's life.

This is only one of the many sad stories of women in the remote areas of far-western Nepal. Even though all over Nepal a woman's status is much less than a man's-in all matters, familial, social, cultural, political and legal-in the far-western regions, it is even worse. A woman's life is valuable only if she gives birth to sons and is fit for arduous work. Many times she has to give up her life to make her family and society happy. At others, she sacrifices her happiness and health to the will of others.

The human development index (HDI) in Nepal is one of the worst in the world and the far-western region has the lowest HDI in Nepal. Although no one is actually healthy here, the burden of disease tends to be heavier for women, because of lack of access to health care. Not only because there are fewer health personnel and fewer health posts and hospitals, but also because they face traditional taboos based on cultural practices and religious beliefs. In Achham, where the female literacy rate is only nine percent (according to government statistics, which generally try to paint a rosy picture), a woman's life are valued less than that of a mule. From the very day she learns to walk, a woman in Achham-as in most far-western regions-starts to work. She will work until the last day of her life. Women here are lucky if they do not die in labour or from postpartum complications, or due domestic violence and countless other preventable reasons.
In many regions in the far-west, women must go to a cowshed or to an outside room, called a chaupati (usually a small bare room with no windows), for labour and delivery, and during menstruation. When she has her period, a woman is "polluted" and must isolate herself. Because of such "pollution", she must also stay in the cowshed for 11 days after delivering a child. Even if she suffering from heavy bleeding or infection she is not touched or treated, and many times, simply dies. Her death is not recorded and the government does not know that a woman has had a maternal death.

We were told many sad events, recounting times when women died in the chaupati because of health problems just because no one dared touch a polluted woman. After spending three weeks in Doti and Achham, and discussing with women about their lives, I started questioning who is to blame for women's appalling status.

When I discussed the harmful cultural practices of keeping women in chaupati and in cowsheds with local political leaders and health workers, I asked them if their wives also follow this practice. They all answered, "Oh yes, they do! We know that it is not a good practice but if our wives do not follow these rituals, we will be ostracised by society. People will stop coming to us." So no political parties, no government employees and no health workers have come forward to talk openly against this practice.

How long will the mothers, daughters and granddaughters of far-western Nepal continue to die and suffer in the name of culture, religion and social norms? We in Kathmandu talk a lot about safe motherhood and make grand plans and programmes to reduce the country's maternal mortality rate by half in the next five years. We give presentations in regional and national workshops, but we never think about the fact that motherhood can never be safe if womanhood remains in danger.