Jaikal Devi Sada from Maintole in Sonama Rural Municipality-7 got married when she was all of 14. The criminalisation of child marriage in the country hasn’t stopped Musahar parents here to marry off their children that young. When she gave birth to her first daughter, Jaikal was 15. Now she is 27 and a mother of five children—the youngest is just three years old. But Jaikal does not have the resources to feed herself and her children. Most days, the family goes to bed hungry, with the young children pestering their mother for food.

With her husband in India for employment, Jaikal shoulders the responsibility of taking care of her children all alone. And it has taken a toll on her health, already weakened by multiple pregnancies. Jaikal now suffers from reproductive health issues like irregular periods and infection in the uterus that have led to purulent drainage. She, however, has not visited a health facility for treatment. She can’t afford it.

“My menstrual cycle is disrupted. I haven’t had my period since March. Most women in our settlement are going through similar health issues, but none of us has gone for a health checkup,” said Jaikal. “My husband is in Chennai in India. He has left me with our children in this tiny one-room hut but with no means to feed ourselves. My husband brings money when he comes, but he doesn’t come home often so I work for daily wages to look after the children.”

Despite the struggles, Jaikal perseveres because she feels she has done her duty by giving birth to a son and is happy in the knowledge that her husband will now not leave her for her failure to produce a son. “I had three daughters before my son was born. My husband had warned me he would leave me for another if I didn’t bear him a son,” she said. “Frequent pregnancies made me weak, but I am happy that at least I have a son now.” Given a deeply patriarchal social structure, most families in Nepal still prefer a son over a daughter.

There are 70 households in the Musahar settlement and most women have a similar story to tell.

Most of the houses have only women, elderly, and children with men going to India to earn a living. Almost every family has four to five children and all families live in crammed huts. The women work as daily wage workers at construction sites to feed themselves and their families.

According to the National Census 2021, 48.7 percent of girls between the ages of 18 and 20 in the rural municipality get married while 40.8 percent of girls get married between the ages of 15 and 17.

Early marriage in the Musahar community is the driving force behind adolescent pregnancy wherein girls have sex before they are physically and emotionally ready, and when they are unaware of their reproductive health and the repercussions of frequent pregnancies.

Kaushila Devi Sada, a 25-year-old woman who is seven months pregnant, is going to become a mother for the fifth time in 10 years. The pregnant woman neither has the money to eat nutritious food nor feed her children. When told how important a nutritious diet is for her and her unborn child, Kaushila says she managed without nutritious food in her previous pregnancies and is certain her latest pregnancy would also not be affected by lack of a good diet.

There is a basic health service centre about 15 minutes from the Musahar settlement in Sonama-7, but the health services extended to pregnant women is limited. According to Ram Sanjog Mahato, public health inspector at the centre, the community health centre provides free examinations to those from disadvantaged groups and offers 45 types of medicine for free. “But the health centres are not fully equipped to diagnose diseases or run tests so most of the time it works as a referral centre,” he said. “There are only two health workers posted at the centre and neither is female. That is also why women do not visit the health centre with their reproductive health issues.”

Under the federal government’s safe motherhood programme, pregnant women in the mountainous, hilly and Tarai regions get Rs3,000, Rs2,000 and Rs1,000, respectively. Additionally, a cash bonus of Rs800 is provided to mothers who complete all four antenatal checkups.

But Kaushila who has never visited the health centre during any of her pregnancies is unaware of such benefits. She, like most women in the settlement, does not visit health centres fearing doctors will recommend various treatments. “If I go to a health facility, they will diagnose my disease and ask me to seek treatment for it in big hospitals. I don’t have the money to do that,” she said. “If I had money, I would rather spend it on food for my children.”

Like Jaikal’s children, Kaushila’s children also keep fighting for food because there is not enough for everyone.

According to Dr Manisha Bhardwaj, a gynaecologist at the district hospital, around 60 percent of women from poor and underprivileged communities in Mahottari who marry at a young age and give birth to children before the appropriate age face complex health problems.

Giving birth before the age of 19 and after 35 is risky for both the mother and the infant, said Bhardwaj. “Being pregnant at a young age not only affects the health of the mother, but also affects the health of the newborn. Problems such as malnutrition, lack of weight gain and lack of the necessary development of bones appear in newborns,” she said.

According to the Madhesh Province Health Directorate, 50 percent of women and children in Madhesh Province are at risk of malnutrition.

Binod Yadav, director of Public Health Services at the Madhesh Province Health Directorate, said that due to early marriage, the number of malnutrition cases in Madhesh Province is becoming alarming. “The families of poor, Dalits, and other underprivileged communities are becoming malnourished due to early marriage. Weak financial conditions contribute to poor reproductive health in women and poor health in children,” said Yadav.

Recently, the District Health Office conducted a cervical health examination of 2,121 women from all eight districts of Madhesh province in coordination with non-governmental organisations. The result of the examination drive showed 59 of the examinees have cervical cancer, and 562 women are at high risk of uterine prolapse.

According to Pratibha Singh, focal person of the health office, the data also suggest that women from Muslim, Dalit, poor, and underprivileged communities, especially those who have married at a young age, given birth to many children, and done hard labour during pregnancy, are at high risk of uterine cancer.

“During the health examination of 640 women in the three local units of Mahottari alone, 91 women had prolapsed uterus and 20 people had cervical cancer,” said Singh.

Aagma Devi Sada, 25, says despite living with serious health issues, women in the settlement avoid health check ups. “We just live with it because we know the health workers will ask us to go to a hospital for treatment. What use are medicines when we are on an empty stomach most days,” she said.