Japan’s maternal health aid in Nepal: systemic gaps persist amid top-down handbook distribution

Nepal’s maternal health has historically relied on indigenous knowledge systems, including the role of *dai* (traditional midwives) and Ayurvedic practices, which emphasize holistic, community-centered care. These systems have been systematically undermined by colonial and post-colonial health policies, as well as modern aid frameworks that privilege Western biomedical models. The JICA handbook initiative risks further eroding these traditions by framing maternal health as a technical problem solvable through standardized materials, rather than a cultural and social one. Indigenous midwifery, for example, incorporates spiritual and communal dimensions of childbirth that are absent in the handbook’s approach.

The JICA handbook initiative echoes colonial-era maternal health programs, which often imposed foreign models of care without addressing structural inequities. Nepal’s maternal mortality rates have historically been tied to broader socio-economic factors, including caste discrimination, gender inequality, and the legacy of the 2015 earthquake, which devastated rural healthcare infrastructure. Foreign aid interventions in the 1970s–90s, often led by Western donors, similarly prioritized technocratic solutions over systemic reforms, leaving behind a fragmented health system. The current handbook distribution also parallels past failures of ‘quick-fix’ health interventions, such as the 2000s push for institutional deliveries without adequate staffing or resources in rural clinics.

Cross-culturally, maternal health outcomes are strongly linked to community trust and cultural relevance, as seen in programs like Bangladesh’s *Shasthya Shebika* (female community health workers) or India’s *ASHAs* (Accredited Social Health Activists). In Nepal, indigenous practices such as *Sutkeri* (postpartum confinement rituals) and the use of local herbs for recovery are integral to maternal well-being but are excluded from the handbook’s biomedical framework. Comparatively, countries like Sweden and Norway achieved low maternal mortality rates not through handbooks alone, but by integrating traditional knowledge with modern healthcare and addressing structural gender inequalities. The JICA initiative risks repeating the mistake of assuming that a one-size-fits-all solution can address the diverse cultural and socio-economic realities of Nepal’s women.

While handbooks can improve health literacy, studies show that maternal mortality in Nepal is more strongly correlated with systemic factors such as access to emergency obstetric care, skilled birth attendants, and the quality of rural health facilities than with lack of information. The World Health Organization (WHO) emphasizes that maternal health interventions must be context-specific, with community engagement and local ownership as key determinants of success. The JICA program’s focus on handbooks aligns with a biomedical model that often overlooks the social determinants of health, including poverty, malnutrition, and gender-based violence. Additionally, the lack of rigorous, peer-reviewed evaluation of the handbook’s impact suggests a gap in scientific accountability.

Maternal health in Nepal is deeply intertwined with spiritual and artistic expressions, such as the *Deusi Bhailo* (traditional postpartum songs) and rituals like *Pasni* (rice-feeding ceremonies), which reinforce social support networks for new mothers. These cultural practices are not merely symbolic but function as mechanisms for emotional and psychological healing, which are critical to maternal well-being. The handbook’s clinical approach, however, reduces childbirth to a procedural event, stripping away the communal and spiritual dimensions that have sustained Nepalese women for generations. Artistic traditions, such as *Mandala* paintings used in postpartum care, also embody holistic health principles that could inform modern maternal health strategies.

Future maternal health strategies in Nepal must prioritize decentralized, community-led models that integrate indigenous knowledge with modern healthcare, such as the *Community-Based Maternal and Neonatal Health* (CBMNH) programs piloted in some districts. Scenario planning should account for climate-induced health risks, such as increased maternal complications due to heat stress and water scarcity, which disproportionately affect rural women. Additionally, the rise of digital health tools (e.g., mobile health apps) could complement handbooks by providing localized, multilingual resources, but only if designed in collaboration with local women and traditional healers. The long-term success of such models hinges on reversing the brain drain of Nepalese healthcare workers and investing in rural infrastructure.

The narrative entirely excludes the perspectives of Nepalese women, particularly those in marginalized groups such as Dalit, indigenous, and rural communities, whose maternal health outcomes are the worst in the country. These women often face discrimination in healthcare settings, lack access to transportation for emergency care, and are excluded from decision-making processes about maternal health policies. The handbook initiative, while well-intentioned, risks further silencing these voices by framing maternal health as a problem solvable through foreign-designed materials rather than systemic change. Indigenous midwives, who are often women from marginalized castes, also face marginalization within the formal healthcare system, despite their proven effectiveness in reducing maternal mortality.