The Role of Cultural Norms in Influencing Women’s Health

Individuals in developing countries often rely on community ties to access key resources due to the absence or inaccessibility of formal institutions. For example, it is commonplace for individuals to rely on their community members (those residing in the same village, neighbourhood or belonging to the same jati/religion) for financial assistance to cover medical expenditures as access to health insurance is not universal in these countries. Reliance on one’s community ties is usually associated with the expectation that an individual would be adhering to the community’s customs and beliefs. The failure to do so usually results in the cessation of all benefits associated with such ties. Therefore, adherence to sociocultural norms is usually found to be strong in developing countries, implying that cultural norms have the potential of influencing individual behaviour and consequently welfare.

In this context, Prof. Bipasha Maity (Assistant Professor, Ashoka University) and her co-author, Rahul Kumar, examined the role of a specific cultural norm, menstrual restrictions, on women’s health-seeking behaviours in Nepal in an impactful study published in World Development Perspectives. 

Menstrual restrictions in Nepal include a range of customs that mandate the seclusion of menstruating women from other individuals in the family and community, along with restrictions on their usual activities and mobility. These customs have arisen from the belief that menstruating women are ritually unclean and need to stay segregated to prevent them from “polluting” other individuals, kitchen spaces, crops, livestock, public spaces, etc. 

Previous studies have demonstrated that women often have no choice regarding whether to follow menstrual restriction-related rituals as they are mandated to do so on account of the prevailing social norms in the community. Moreover, childbirth is considered just as ritually unclean as menstruation. Therefore, postpartum confinement practices along the lines of menstrual restrictions followed by ceremonies involving ritual purification of the new mother and infant are widespread in Nepal. 

This motivated the researchers at Ashoka University to study how facing any menstrual restriction like rituals can affect women’s healthcare access around the time of childbirth. Since maternal mortality and morbidity rates in Nepal remain higher than the global average, understanding the extent to which cultural norms such as menstrual restrictions help sustain barriers to accessing maternal healthcare is of immense policy relevance.

The authors used nationally representative data called the Multiple Indicator Cluster Survey (MICS), 2014 collected by UNICEF for the analysis. The MICS includes rich information on the socio-economic and demographic characteristics of ever-married women of reproductive age and is the only dataset that includes information on menstrual restrictions faced by respondents. The authors chose to focus on the respondent’s place of delivery and whether assistance was received from medically trained personnel (doctors, nurses, skilled birth attendants) at the time of childbirth. This information was available for the last child born within two years from the survey. While this does not capture maternal healthcare access for one’s entire fertility history, its advantage lies in reducing recall bias about past healthcare utilization.  

Using several existing and recent advances in econometric methodologies, Ashoka researchers found that facing menstrual restrictions is indeed associated with a significantly higher likelihood of giving birth at home and receiving assistance only from informal sources (such as one’s relative/friend) at the time of giving birth. Home births and especially without the assistance of medically trained personnel have been shown to increase the risk of maternal morbidity (e.g.: uterine prolapse) and mortality through excessive blood loss, septic shock. 

The findings continue to hold even if adherence to some of the strictest customs is omitted, indicating that any ritual that mandates some isolation and restricts mobility adversely influences maternal healthcare access. However, facing any menstrual restriction was not found to influence antenatal care utilization; plausibly because the concern of ritual uncleanliness is not of paramount concern during pregnancy as it is at the time of childbirth. Therefore, menstrual restrictions are unlikely to influence healthcare utilization at a time when concerns about ritual uncleanliness are largely absent. 

This study demonstrates the role of cultural norms in impeding access to healthcare at a critical time for women and children; thereby making progress towards sustainable development goals (SDGs) slow. Further, isolation and limited healthcare access post-childbirth can exacerbate the incidence of postpartum depression and delay its diagnosis. Therefore, studying the role of cultural norms in influencing mental health is an important area of future research.

(Edited by Dr Yukti Arora)

Reference Article: Cultural norms and women’s health: Implications of the practice of menstrual restrictions in Nepal, World Development Perspectives, September 2022 | Volume 27 | Article 100450

Authors: Rahul Kumar and Bipasha Maity