602743

research-article2015
APHXXX10.1177/1010539515602743Asia-Pacific Journal of Public HealthRanabhat et al

Article
Asia-Pacific Journal of Public Health
2015, Vol. 27(7) 785795
Chhaupadi Culture and 2015 APJPH
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DOI: 10.1177/1010539515602743
Women in Nepal aph.sagepub.com

Chhabi Ranabhat, MPH, PhD1,2,4,

Chun-Bae Kim, MD, PhD1,2, Eun Hee Choi, PhD3,
Anu Aryal, BSc N5, Myung Bae Park, MPH, PhD1,
and Young Ah Doh, PhD, MPA, PHD6

Abstract
Different sociocultural barriers concerning womens health are still prevalent. Chhaupadi culture
in Nepal is that threat wherein menstruating women have to live outside of the home in a
shed-like dwelling. Our study aims to determine the factors of reproductive health problems
related to Chhaupadi. A cross-sectional study was performed with women of menstrual age
(N = 672) in Kailali and Bardiya districts of Nepal. Data were collected with stratified sampling
and analyzed using SPSS. Reproductive health problems were observed according to the World
Health Organization reproductive health protocol. Regression analysis was performed to show
the association between relevant variables. Results reveal that one fifth (21%) of households used
Chhaupadi. Condition of livelihood, water facility, and access during menstruation and precisely
the Chhaupadi stay was associated (P < .001) with the reproductive health problems of women.
The study concludes that Chhaupadi is a major threat for womens health. Further research on
appropriate strategies against Chhaupadi and menstrual hygiene should be undertaken.

Keywords
Chhaupadi, reproductive health problems, menstrual hygiene, cross-sectional

Introduction
Menstruation is a normal physiological process in women, but it is perceived differently in
diverse societies and cultures.1 There are some beliefs that culture related to menstruation has
been linked with religion, which is unfair. Most Christians do not follow any rituals or beliefs
related to menstruation,2 except for some eastern orthodox church followers including Russians,

1Department of Preventive Medicine, Yonsei University, Wonju College of Medicine, Wonju, Republic of Korea
2Institute for Poverty Allivation and International Development Yonsei University, Wonju, Republic of Korea
3Institute of Life Style Medcine, Yonsei University, Wonju College of Medicine, Wonju, Republic of Korea
4Health Science Foundation and Study Center, Kathmandu, Nepal
5Good Neighbors International, Jhamsikhel Lalitpur, Nepal
6Korea International Co-operation Agency, Africa and South America Section, Seoul, Republic of Korea

Corresponding Authors:
Chhabi Ranabhat and Chun-Bae Kim, Department of Preventive Medicine, Yonsei University, Wonju College of
Medicine, Wonju, Gangwon 220-701, Republic of Korea.
Email: chhabir@gmail.com; kimcb@yonsei.ac.kr

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786 Asia-Pacific Journal of Public Health 27(7)

Figure 1. Chhaupadi in Tikapur, Kailali, Nepal.

Video available at: https://www.youtube.com/watch?v=UgQ54CZ6uLQ

Ukrainians, or Greek, and they advise women not to be in close relationship with others.3 Judaism
and traditional Islamic interpretation of the Quran prohibits intercourse, but not physical inti-
macy during a womans menstrual period.4 Hinduism has a wide diversity of culture on men-
struation and there are mixed interpretations. Buddhist people take menstruation as a natural and
normal physiological process, but Japanese Buddhist do not encourage attendance at worship
during this period.5 In middle India, including some parts of Nepal, menarche, the first menstrua-
tion, is a positive and productive time in a womans life. In south India, when girls experience
their first menstruation, they are given presents and there are celebrations to mark this special
occasion.6 Nevertheless, some cultural practices result in women facing isolation during men-
struation, and one of these cultures is the Chhaupadi culture of Nepal.
A number of taboos and sociocultural restrictions still exist concerning menstruation, which
intimidate women and makes their life difficult.7 The most common social and cultural practices
and restrictions during menstruation among young girls and women are the following: prohibi-
tion to enter the prayer room and the kitchen,8 looking into a mirror, attending to guests,9 offering
prayers, and touching holy books.10 Menstruating Taiwanese women have been found to avoid
particular substances and behaviors, such as cold and raw food, exercise, and tub baths, to main-
tain their menstrual hygiene.11 Perception about menstruation are still clouded by taboos and
sociocultural restrictions because they are ignoring scientific facts and the menstrual hygiene
aspect that could provide better reproductive health.12 Due to the negative perception about men-
struation, women feel some sort of stigmatization and inadequate sanitation that have important
consequences for their sexuality, well-being,13 as well as reproductive health problems due to
poor hygiene.14 The aforementioned studies indicate that more beliefs related to menstruation are
prevalent in South East Asia including in some parts of Nepal; however, these findings are silent
in with regard to womens reproductive health and sufficient hygiene.
Chhaupadi culture is a traditional practice wherein menstruating women have some restric-
tions, such as restrictions to consume of milk products; restricted access to public water sources;
not being allowed to touch men, children, cattle, living plants, or fruit bearing trees15; and having
to live outside the home such as in an animal shed16 (Figure 1). This practice is widespread in the
far west and some parts of the mid-western Nepal.17 It is one kind of violence against women, and
there is equal chance for mental health problems because womens mental health was worsening
due to domestic violence in a study in Turkey.18 Anemia and underweight (body mass index <18)
of women was 2-fold higher and child health status was poor in Chhaupadi-affected areas in

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Ranabhat et al 787

comparison with the national average because small children live together with their mothers in
Chhaupadi during the menstruation period.19 Reproductive health problems like severe bleeding,
backache, and lower abdominal pain are worsening during Chhaupadi stay and some of the
women fall prey to negative health behaviors such as smoking and alcohol consumption through-
out their Chhaupadi stay.20 Genital infections due to lack of menstrual hygiene, undernutrition
due to some food barriers, and uterus and cervical problems due to heavy working, and recurrent
infection of human papillomavirus are the major consequences due to Chhaupadi stay.21
Chhaupadi itself does not cause any disease or illness, but it facilitates an unsafe menstruation
period. As a result, it increases reproductive tract infection for women due to poor hygiene (lim-
ited access to water) and maternal malnutrition (some food restriction), and after continued use it
increases behavioral problems (due to isolation, substance abuse, and stigmatization). The base-
line health survey on health service improvement in Tikapur (HIT) 2012 states that 30% of
households in that community practice Chhaupadi.22 These studies and reports indicate that
Chhaupadi might be a major cultural factor that is responsible for poor womens health status.
The research related to menstruation belief and culture are very few, and the issues related to
Chhaupadi also have not been widely explored because of the social structure: dominated status of
male and offensive situation of female and linking of culture with religion. Likewise, there are few
scientific research studies and they explored the Chhaupadi problem as social inequality, which is
a very general and ambitious subject. It means there is not only lack of research on Chhaupadi but
also specification of study so that it could be point out the direct effect. In other words, womens
reproductive health must be the prime concern and inequality, rights, and so on are secondary
concerns. There is multiple impact of Chhaupadi culture but this study is focused on reproductive
health problems of women due to unsafe menstruation. The aim of this study is to determine the
factors on reproductive tract infection based on the World Health Organization (WHO) protocol in
relation to Chhaupadi stay in Kailali and Bardiya districts of Nepal. Our expected outcome is to
bring about improvement of Chhaupadi culture for the better reproductive health of women.

Methodology
Study Design and Sampling
This was cross-sectional study conducted from June to August 2014. More explicitly, it is descrip-
tive and some components were framed as analytical. The sampling process was set up in 3 stages.
The women of menstruation age based on households were the study unit. Study districts were
selected purposively as Bardiya and Kailali districts of Nepal, which are the areas occupied by the
migrants who are inhabitants of places where Chhaupadi originated. In the second stage, 6 village
development committees (VDCs), which are government geographical units, were selected by
simple random sampling in the selected districts. In the last stage, participants were selected from
households.

Sampling Strategies
The 3R strategy was applied in the sampling process: randomization of participant selection,
representativeness by proper estimation of sample size, and reliable information through field
researcher selection, training, and data collection with proper supervision.

Sampling Frame
Individual participants were selected from the list of the local government authority: VDC record
list of selected strata. Stratified random sampling was applied to include a subgroup of the popu-
lation based on population weight. Below the VDC unit, there were also ward-level (Nos. 1-9)

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788 Asia-Pacific Journal of Public Health 27(7)

population subgroups because all subgroups were included by disproportionate stratified random
sampling.

Sample Size Estimation

Previously, baseline health survey for health improvement in Tikapur (HIT) explored that 30% of
households had Chhaupadi.22 Based on that study, the sample size was calculated by an online
software23 using the following formula:

Z 2 p (1 p )
n= ,
d2
where n is the sample size, the value of Z is 1.96, p is the proportion (30%) of staying at
Chhaupadi,22 and d is the standard error (0.01). The sample size was 336 per district, and our
study was in 2 districts.

Selection of Participants
Females who were of mensuration age (usually 12-49 years) and those who had already started
the menstruation process were included in the study. One participant was selected from each
household. If there were more than one respondent in the household, the latest menstruating
woman was selected. Females who having menopause, those staying in the study region for less
than 6 months, households that did not have women of menstruation age, and those who did not
want to participate in the study were excluded from this study.

Recruitment of Field Researchers

The field researchers were screened and selected based on previous experience, academic sound-
ness, and experience with field research. More consciously, the researchers were selected from
health education backgrounds such as paramedics, nurses, and community health workers because
they could screen the reproductive health problems of women.

Setting of Research Tool

A semistructured questionnaire was developed based on observation of Chhaupadi, focus group
discussion with community key informants, field-level health workers, previous reports related
to Chhaupadi, and survey findings of the health services in Tikapur (HIT), Nepal. Health prob-
lems of women were developed based on comprehensive cervical cancer control manual 2006
(WHO)24 and guidelines for the management of sexually transmitted infections 2003 (WHO),25
particularly reproductive tract infection as shown in the question below.

Have you had any of the following problems over the past 1 year?
1. Severe pain and/or foul-smelling discharge during menstruation? 1. Yes
2. No
2. Experience of burning during urination? 1. Yes
2. No
3. Vaginal itchiness? 1. Yes
2. No
Any abnormal discharge and/or swelling in your vagina? 1. Yes
2. No
Measurement: Any one of those problems or more than one or all of them = present (1);
and none of them = absent (0)

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Data Collection Method, Instrument, and Variables

Data were collected by field researchers with the help of the complete questionnaire and field
guide book. First, the collected data were decoded and entered in Epi Data 3.1 data entry format
and exported to SPSS 20. Data were cleaned and verified by a biostatistician and further analyzed
by researchers. There were 3 categories of independent variables: demographic (age, ethnicity,
education marital status, and district), economics (condition for livelihood, occupation, housing
condition, availability of toilet and water), and menstruation-related variables (use of pad, bath-
ing attitude, accessibility of water, and Chhaupadi stay) and presence and absence of reproduc-
tive health problems as dependent variables as in the aforementioned table.

Statistical Test
Categorical variables are presented as frequency and percentage. In order to compare reproduc-
tive health problems, we performed the 2 test (Fishers exact test). Logistic regression analysis
was used to identify the factors to predict the reproductive health problems. This was quantified
by odds ratio using binary logistic regression. P value less than .05 was considered statistically
significant, and all statistical analyses were performed using SPSS 20.

Validity and Reliability

The research tools were verified in a pilot study in a similar area in Baliya VDC Kailali, the
sample size was determined by a scientific method, appropriate selection of researchers training
and field guidebooks were provided for reliable data, the data collection process was supervised
to minimize bias, and related variables were adjusted to find the fair result.

Ethical Issues
The research was approved by the Ethical Review Committee of Nepal Health Research Council,
and verbal consent was obtained from the respondents during data collection. For girls under the
age of 16, consent was taken from their parents after describing the research objectives in detail.
All respondents were requested to provide information voluntarily and were assured that they
could withdraw anytime during the study.

Results
Descriptive Data
The respondents were selected from 3 VDCs in each district, that is, Pathariya 21%, Kotatulsipur
13%, and Durgauli 16% from Kailali; and Patabhar 17%, Manau 7.4%, and Sanoshree 26%
from Bardiya. Both indigenous people (45.5%) and those who had migrated from other places
(54.5%) made up the study population. Of the women, 36% were 20 to 30 years old, almost all
(98%) were of the Hindu religion, and 42% were from poor families (unable to maintain a liveli-
hood all year round). In aggregate, 25% reported one or more problems related to their reproduc-
tive health.

Characteristics of Demographic, Economic, and Menstruation-Related Variables

With Reproductive Health Problems
The variables were categorized into 3 sections, and all independent variables were dichoto-
mous. Ethnicity (upper caste), respondents of the Kailali district, economic status not suffi-
cient for livelihood, risky house, food restriction during menstruation, no access of water

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790 Asia-Pacific Journal of Public Health 27(7)

during menstruation, bathing habit on more than 2 days, and staying in Chhaupadi had signifi-
cantly higher reproductive health problems than who had not (Table 1). Likewise, all reported
health problems were strongly associated (<.001) with Chhaupadi stay (Table 2). It was fur-
ther explored that almost all menstruation variables were related to reproductive health
problems.

Situation of Reproductive Health Problems After Adjustment

After the adjustment of predictors using the binary logistic regression, some variables are risk
factors to the reproductive health for women. The odds ratio with 95% confidence interval
showed that respondents from Kailai 2.38 (1.36-4.18), no utilization of water resource during
menstruation 2.78 (1.32-5.88), and who had Chhaupadi 14.6 (6.99-30.5) times risk to have repro-
ductive health problems and were statistically significant (P < .05; Table 3). Among all signifi-
cant predictors, the Chhaupadi was a high risk factor as reproductive health problem before 30.47
(18.66-49.77) and after final adjustment 14.6 (6.99-30.5), model IV (P < .001).

Discussion
Currently 20% of the households practice Chhaupadi, a slight decrease from the previous
30%,22 and such culture was deeply rooted in the migrated community from Achham, Dailekh,
and Bajhang districts, which are known as a source of Chhaupadi culture. In comparison with
Kailali, Bardiya district has low of influence of migration from those districts. As a result, the
reproductive health problems were significantly lower in Bardiya district. This study indi-
cates that not only menstruation-related factors but also demographic and economic factors
are responsible for womens reproductive health problems (Table 1), because they are com-
mon factors in most of the studies, but here menstruation-related factors are primary factors.
Some food restriction and access to public water sources are menstrual culture without
Chhaupadi also.
The studies on unsafe menstruation and reproductive health problems are very rare but avail-
able comparisons are presented. A study in India indicates that food and some activities are
restricted during menstruation, and the average index score was comparatively high for the
respondents in the categories of unmarried status, semiurban areas, Hindus, joint family struc-
ture, and high school level of education.26 A practice in Judaism, Mikvavh, consisting of ritual
bathing that occurs at the end of the menstrual period, has been reported as harmful to womens
health.27 In some Chinese cultures, menstruation is perceived as a weak condition and cold foods
and drinks are restricted and herbal teas are recommended for strength (Qi).28 Like the Chhaupadi,
there is a similar practice in India for menstruating women to restrict some foods like milk, fruits,
and so on, and some important activities. However, another study in India found no significant
relationships between attitudes to menstruation and demographic variables.29 These above-men-
tioned study findings are similar with our result.
There are specific beliefs about food that women are restricted on eating during menstrua-
tion, pregnancy, and lactation, usually in rural areas of Nepal.30 More than 20% of the women
in Kailali and Bardiya districts have low body mass index (<18.5 kg/m2), which should be proxy
indicators of food restrictions during their menstruation.31 The reproductive health problems
like burning micturition, chronic pelvic pain, painful sexual intercourse and pain occurring dur-
ing period, abnormal discharge, and so on are the symptoms of fibroid uterus, multiple repro-
ductive tract infection, and cervical and uterus cancers, which are more severe and sometime
fatal.32 During the screening for uterine prolapse, the women reported health symptoms as dif-
ficult and burning urination, abdominal pain, backache, painful intercourse, white watery dis-
charge, foul-smelling discharge, itching, and difficulty in lifting, sitting, walking, and standing

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Ranabhat et al 791

Table 1. Characteristics According to Reproductive Health Problems (N = 672)a.

Reproductive Health Problems

Absent Present
Variables Category (N = 503), n (%) (N = 169), n (%) P Value

Demographic variables
Age <30 years 315 (62.6) 108 (63.9) .7654
30 years 188 (37.4) 61 (36.1)
Ethnicity Lower cast 272 (54.0) 34 (20.1) <.0001
Upper caste 231 (46.0) 135 (79.9)
Education Higher education 89 (17.7) 27 (15.9) .6092
Lower education 414 (82.3) 142 (84.1%)
Material status Married 349 (69.3) 125 (73.9) .2584
Unmarried 154 (30.7) 44 (26.1)
District Kailali 195 (38.8) 141 (83.4) <.0001
Bardiya 308 (61.2) 28 (16.6)
Economics variables
Condition for livelihood Sufficient livelihood 309 (61.4) 78 (46.1) .0005
Insufficient livelihood 194 (38.6) 91 (53.9)
Major occupation Paying job 12 (2.3) 3 (1.8) .7718
Not paying job 491 (97.7) 166 (98.2)
Type of house Relatively safe 177 (35.2) 44 (26.1) .0284
Weak/dwelling 326 (64.8) 125 (73.9)
Toilet Yes 398 (79.1) 111 (65.7) .0004
No 105 (20.9) 58 (34.3)
Water facility at home Yes 442 (87.9) 155 (91.7) .1698
No 61 (12.1) 14 (8.3)
Menstruation-related variables
Food restriction during menstruation Yes 141 (28.0) 116 (68.6) <.0001
No 362 (72.0) 53 (31.4)
Application of pad Yes 493 (98.1) 168 (99.4) .3069
No 10 (1.9) 1 (0.6)
Utilization of water resource during Yes 424 (84.2) 49 (28.9) <.0001
menstruation No 79 (15.8) 120 (71.1)
Bathing attitude during menstruation Daily 420 (83.5) 158 (93.5) .0012
More than 2 days 83 (16.5) 11 (6.5)
Chhaupadi Yes 29 (5.8) 110 (65.1) <.0001
No 474 (94.2) 59 (34.9)

aTotal percentage by column.

Table 2. Component of Reproductive Health Problems According to Chhaupadia.

Chhaupadi Stay

Reproductive Health N = 139; N = 533;

Problems (Present) Yes, n (%) No, n (%) P Value
Burning micturition 89 (64.0) 15 (2.8) <.0001
Abnormal discharge 67 (48.2) 29 (5.4) <.0001
Itching in genital part 77 (55.4) 26 (4.8) <.0001
Pain and foul smelling 55 (39.5) 18 (3.3) <.0001
menstruation
aReproductive health problems exceed 169 because of the duplication in numbers.

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 792
Table 3. Odds Ratio and 95% Confidence Interval for Reproductive Health Problems.

Variables Category Model I; OR (95% CI) Model II; OR (95% CI) Model III; OR (95% CI) Model IV; OR (95% CI)
Chhaupadi Yes 30.47 (18.66-49.77)** 18.72 (10.16-34.5)** 19.68 (10.55-36.71)** 14.60 (6.99-30.50)**
No 1 1 1 1
Demographic variables
Ethnicity Lower cast 0.94 (0.54-1.64) 0.95 (0.54-1.68) 1.18 (0.62-2.25)
Upper caste 1 1 1
District Kailali 3.19 (1.91-5.34)* 2.85 (1.65-4.93)* 2.38 (1.36-4.18)*
Bardiya 1 1 1
Economics variables
Economic status Insufficient livelihood 1.53 (0.95-2.46) 1.61 (1.0-2.62)
Sufficient livelihood 1 1
Type of house Weak/dwelling 1.11 (0.65-1.89) 1.2 (0.7-2.05)
Relatively safe 1 1
Toilet No 1.22 (0.72-2.06) 1.21 (0.71-2.05)
Yes 1 1
Menstruation-related variables
Food restriction during Yes 0.66 (0.31-1.39)
menstruation No 1
Utilization of water resource during No 2.78 (1.32-5.88)*

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menstruation Yes 1
Bathing practice More than 2 days 0.77 (0.35-1.7)
Daily 1

Abbreviations: OR, odds ratio; CI, confidence interval.

*P < .05. **P < .001.
Ranabhat et al 793

in Bajhang district of Nepal, which is a Chhaupadi-affected place.33 Reproductive tract infec-

tions and uterovaginal prolapse were the leading causes of maternal morbidity34 that were
reported in those areas. These results are similar to our study concerning the 4 reproductive tract
infections we accessed.
Society is complex and it is dynamic because different communities have different myths,
values, taboos, and cultures. Previously, there have been general studies on Chhaupadi from the
perspective of womens rights and violence against women. In those areas government agencies
and communities have declared Chhaupadi-free societies and some improvement can be observed
but these were not to address the reproductive health problems of women. Chhaupadi culture is
against the law; however, there is no sufficient law enforcement to change the community.16,35 So
only womens effort is not sufficient for this threat, mens role is invaluable because the coverage
of antenatal care was significantly increased especially for newly married women with the help
of their husbands in Bangladesh.36 According to the evolution of society, such menstrual taboo
will disappear eventually, but by that time, many women and children will have died or suffered
from health problem due to unsafe menstruation in those areas of Nepal.

Limitation of the Study

No standard instruments were used for this study, but the reproductive health problems were
measured to the WHO reproductive health protocol.24,25 The results of this study may not confirm
reproductive health diseases of the women clinically or by laboratory and only show the vulner-
ability to any type of reproductive tract infections due to unsafe menstruation. There might be
recall bias regarding the reproductive health problems over the past 1 year, and 4 reproductive
health problems may not represent the overall health status of women, but our results strongly
support the Chhaupadi as a risk factor of reproductive health of women.

Policy and Public Health Implication

Basically, this study aims to improve the reproductive health of women and provide more atten-
tion to policymakers and health service provider where the Chhaupadi is high and a special pro-
gram could be set so that the reproductive health problem will be explored in more detail.
Menstrual hygiene is the main requirement to control reproductive tract infection and the govern-
ment should conduct a special campaign about it. Moreover, Nepals Ministry of Health and
Population could formulate a safety menstruation policy targeting any kind of menstruation mal-
practice that is responsible for the poor health status of women. It also drives to make more strict
laws against Chhaupadi in Nepal and appealing reproductive right act to eliminate all kinds of
cultural violence that are threats to womens health.

Conclusion
Chhaupadi is responsible for reproductive health problems due to unsafe menstruation. Menstrual
hygiene is important to reduce the reproductive health problems because bathing attitude was
also significant to reproductive health problems. The Millennium Development Goals are focused
on improving the health of women but some inequality and women unfriendly cultures are main
threats to improve their health.37 More clinical research, safe menstruation policy, special pro-
grams through global effort, collaboration between different organizations, and so on could be a
milestone to overcome the problems.

Acknowledgment
This article was reviewed by Margret Stroey.

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794 Asia-Pacific Journal of Public Health 27(7)

Authors Note
Chhabi Ranabhat and Chun-Bae Kim contributed equally to this work.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or
publication of this article.

Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publi-
cation of this article: This study was supported at the field level with initiation of Good Neighbors
International Nepal and the National Research Foundation Grant of Korea, Korean Government for the
publication (NRF-2013S1A5B8A01055336).

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