While older women in Karnali Province lived through child marriage, malnutrition and high maternal and infant mortality, a younger generation is increasingly moving away from restrictive traditions by adopting modern healthcare and professional medical advice.

Sugani Damai, 48, from Rokayagaun in Adanchuli Rural Municipality-3, Humla, was married at age 5. She became a mother at 16 and lost her first child soon after birth.

“He was underweight at birth and grew weaker and thinner. He died within a few months,” Sugani recalled. “I lost my firstborn. The memory still haunts me.”

She later realised her son likely died due to malnutrition. She went on to have two more sons. At the time of her delivery, feeding colostrum—the thick, yellow milk available after childbirth—was uncommon.

“There was no tradition of feeding the initial milk. Instead, babies were bathed immediately after birth. I gave birth in the snowy season; I still remember bathing my baby with snowwater,” she said.

In her mountainous district, she said, food scarcity was common.

“We are people from the mountains. Food was hard to find, and even what we grew ourselves was not always allowed to be eaten, as people feared it would make us ill,” she said. “During the postnatal period, I was not allowed pulses or lentils. I could only eat plain rice and dry roti, and even then never had my stomach full.”

After losing her first child, she delivered a stillborn. She believes this may have been due to her inability to take care of herself during pregnancy. Even while pregnant, she continued heavy labour with little change in diet or routine.

“That is why I lost my daughter at the end of my term. Only my second and third children survived,” Damai said. “With no other option to prevent pregnancy, I even consumed bear’s bile.”

She said maternal health was not prioritised in those days. Whether pregnant or postpartum, she was always engaged in heavy labour.

Now a mother-in-law, Sugani sees a considerable improvement in the circumstances for her daughter-in-law.

Married at 17, Kalpana visited the local post for check-ups during pregnancy and spaced her children appropriately.

“I took care of myself exactly as health workers advised. I never stayed hungry,” she said. “I ate nutritious food and fed my baby colostrum. The baby was only bathed after 24 hours.”

She said she followed medical advice on diet and avoided taboos.

The custom of restrictive dieting from my mother-in-law’s time is disappearing, Kalpana said.

She added that she consumed available meat, fish, eggs, greens and pulses during and after pregnancy, and remained cautious with physical work.

Seventy-year-old Jayasara Neupane of Nanikot in Pachaljharana Rural Municipality-8, Kalikot, was married at the age of seven. Her husband was 11 at the time of marriage. She gave birth to her first child at the age of 20.

After that, 13 children were born in quick succession, she said. “Only seven survived.”

She often did not know the causes of death.

“Some died of fever, some cough, others from vomiting. We did not know what caused it,” she said.

She said there was little awareness of maternal nutrition or rest during pregnancy.

“Forget nutritious food, we could not even rest properly,” she said. “I had to do all the household chores. No one knew a pregnant woman needed care.”

She said dietary restrictions were common, including avoidance of leafy greens, fruits, milk and curd during pregnancy and after childbirth.

“Even when meat and fish were available, it was not customary for new mothers to eat them,” she said. “Only now do I realise I was kept away from the very foods I needed the most.”

She now wonders whether better nutrition or medical access could have saved more of her children.

“There was not even a health post to treat sick children,” she recalled. “If I could have taken them for treatment, they might have lived.”

Jayasara says her experience represents most women of her generation in Karnali. She is now struck by the differences in the lives of younger women.

“They have fewer children and go to hospitals for delivery. Doctors check them regularly,” she said. “They do not have to fast or avoid food. In our time, there was neither enough food nor medicine.”

Her eldest daughter-in-law experienced some improvements in care, while her youngest daughter-in-law, Tulsi Neupane, has had a very different experience altogether.

Tulsi married into the family 10 years ago at the age of 21 and has two children. She said planned pregnancies and access to healthcare made a major difference.

“I cannot believe the stories of women giving birth while cutting grass or walking home after labour pains began in the fields,” she said. “That era is gone.”

She said she attended regular check-ups and gave birth at health facilities.

“If there was any problem, we consulted health workers or doctors,” she said. “I did not have to avoid any foods during pregnancy. My husband also supported me.”

Goma Koirala, 71, of Narayanpur Municipality-1 in Dailekh, is a mother of five. She married at 18 and had her first child a year later. All her children were born at home.

“In our time, there was no practice of going to the hospital for delivery,” she said. “We gave birth at home while doing household chores. We suffered a lot.”

She said postnatal dietary restrictions were strict.

“We could not eat greens, meat, fish or pulses when we needed nutrition the most,” she said. “I still wonder how we survived.”

She considers herself fortunate not to have been forced into chhau goth (the menstrual shed) after childbirth.

“I remember many women dying during or after childbirth,” she said. “Some died from excessive bleeding or because the placenta did not come out. Those who survived did so by chance.”

She now understands that poor maternal nutrition contributed to many of those outcomes.

Her daughter-in-law, Sangeeta Pandey, married at 22 and has two children, both delivered at a district hospital.

“I did not suffer like the older generation,” Sangeeta said.

Even in relatively better-off households in Karnali province decades ago, pregnant women had limited access to nutritious diets.

Today, however, health workers say awareness and access have improved significantly.

Tulsi Shahi, an Auxiliary Nurse Midwife at Pulu Health Post in Mugum Karmarong Rural Municipality-5 of Mugu, said institutional deliveries and dietary awareness have increased.

“There used to be beliefs that sour food would harm the baby or pulses would cause illness,” she said. “Now pregnant women eat greens, pulses and citrus fruits.”

She said more women are visiting health facilities as soon as they confirm pregnancy.

“They receive counselling and care,” she said. “Maternal and postnatal health is improving.”

Statistics reflect the trend. Twenty-one women died during pregnancy or childbirth in Karnali Province in the financial year 2019-20. By 2022-23, the number had fallen to 17.

Infant deaths also declined from 204 in 2019-20 to 168 in 2022-23, according to provincial data.

Local governments have introduced nutrition allowances and incentives for antenatal check-ups and institutional delivery to improve outcomes.

Data from the Health Service Directorate in Surkhet shows that institutional deliveries remain high, with fluctuations in home births over recent years.

28,091 women delivered their babies in health facilities across Karnali in 2025-26, while 1,238 delivered at home.

In 2022-23, there were 29,561 institutional deliveries and 488 home births. In 2021-22, there were 30,007 institutional deliveries and 3,109 home births.

Navaraj Kandel, information officer at the directorate, said the provincial government provides Rs 2,000 as a nutrition incentive for new mothers. Under the federal Aama Surakshya programme, women who complete four antenatal visits and deliver in health facilities receive Rs 3,800.

A nutrition support programme is also being implemented in five mountainous districts of Karnali.

Paediatrician Navaraj KC of Karnali Care International Hospital and Research Centre Pvt Ltd said progress has been made, but gaps remain.

“Compared to before, awareness of maternal and child health has increased, and indicators have improved,” he said. “But more needs to be done. Food is available, but awareness of proper nutrition during pregnancy is still lacking.”

He also said cultural practices still affect women’s health.

“Restrictions during menstruation and after childbirth still exist,” KC said. “If women cannot even stay safely inside their homes, how can they get proper nutrition?”