How gender inequality drives drug resistance in Nepal
The risks of pregnancy and childbirth, restricted decision-making power and the pressure of keeping the household ticking over place women at greater risk of antibiotic misuse, learns Chhatra Karki in Kathmandu.
- 15 September 2023
- 5 min read
- by Chhatra Karki
After three years on the job at Pokharbhinda health post in Nepal's Siraha district, Auxiliary Nurse Midwife (ANM) Bhawana Yadav has made a few observations about the different ways male and female patients interact with the health system.
This one troubles her: women often request amoxicillin and azithromycin, two common antibiotics, in hopes of expediting recovery from the mild, and typically virus-associated symptoms of a common cold, she says.
Devkota says that the government of Nepal is planning to undertake a comprehensive study on AMR and develop a prevention programme.
"Women often shoulder a significant burden of household chores compared to men," she posits. "When women fall ill, their responsibilities, like childcare, cooking, farming, and tending to cattle, are disrupted. As a result, they frequently request antibiotics to speed up their recovery. However, it's not widely understood that using antibiotics in this manner can weaken the ability to combat illnesses."
But even when the health centre's medical staff do not recommend antibiotic drugs for patients' illnesses, they often chose to purchase them from private medical shops, she says.
Too many drugs
Dr Bibeka Shrestha, a Clinical Consultant with the USAID Medicines, Technologies, and Pharmaceutical Services (MTaPS), agrees that the susceptibility to the trends of antimicrobial resistance (AMR) does appear to be gendered, with women appearing more susceptible to drug resistant infections than in men. She believes that the risk of AMR infections could particularly rise during pregnancy, childbirth, menstruation, and abortion in women, as a consequence of overprescription or overuse of antimicrobials in these vulnerable periods of a woman's life.
"In my experience, government hospitals in Kathmandu tend to administer fewer antibiotics during pregnancy. Conversely, in many private hospitals, antibiotics are prescribed to pregnant women as a quick solution,'" Dr Shrestha says.
Gendered use of antibiotics is not a tendency limited to Nepal. A wide-ranging 2016 research review article written by a group of scientists from the University of Tübingen in Germany, and published in the Journal of Antimicrobial Chemotherapy, by Schroder and colleagues, found that women were 27% more likely to receive an antibiotic prescription in their lifetimes. The paper also highlighted that women faced higher susceptibility to AMR due to factors like more limited access to education, restricted health information and prevailing social and cultural norms.
Dr Santosh Dulal, a senior technical advisor and research scientist with USAID MTaPS, says that in developing countries pregnant women face an elevated risk of AMR due to the use of antibiotics in for pre- and post-surgical birth-related wounds.
Have you read?
"Frequent and repetitive antibiotic use can diminish the body's capacity to combat diseases and result in severe health complications. There have been instances where women's lives were jeopardised due to antibiotic ineffectiveness,"' Dr Dulal emphasises. "The risk of AMR escalates when women experience multiple pregnancies, undergo numerous abortions, and when the birthing environment becomes unsanitary during childbirth."
Women are also overrepresented in healthcare, meaning they face a heightened risk of AMR due to their frontline roles.
Further, Dr Shrestha points out that as women in rural Nepal primarily rely on agriculture and are often in charge of handling a family's production animals, they may be exposed at higher rates to the antibiotics administered to animals.
Too little knowledge
In a 2022 article featured in the journal Frontiers in Global Women's Health, meanwhile, researchers found that women tended to be excluded from healthcare decision-making, and that sick women were broadly less likely to seek treatment than men.
There is a prevalent cultural practice of avoiding hospital visits for health issues, with men often purchasing antibiotics for women, explains Dr Bikash Devkota, Additional Secretary at Nepal's Ministry of Health and Population. Devkota notes that this situation is exacerbated by the misconception that antibiotics are the sole or best remedy for illness.
He mentioned that there is a significant lack of public awareness regarding AMR, and even local-level elected representatives are often uninformed about it.
Devkota says that the government of Nepal is planning to undertake a comprehensive study on AMR and develop a prevention programme. They have already conducted AMR awareness programmes in certain hospitals and established committees in various provinces for this purpose. He adds, "In the upcoming initiative, the topic of gender impact on AMR will also be addressed."
Dr Dulal, meanwhile, points out that Nepal has yet to conduct research on AMR under the One Health Policy, which considers human, animal and environmental health jointly. The result is a problematic absence of data and analysis on the subject.
He underscores the importance of approaching AMR as a multisectoral challenge, demanding research on humans, animals, and plants. Furthermore, he reiterates the necessity of including the dimension of gender in these efforts.
Despite experts often referring to AMR as the "silent pandemic", stressing its existential risks, in Dr Dulal's view, Nepal is underprepared to tackle it. He notes that although the Government of Nepal has prepared a National Action Plan on AMR (2021-26), its endorsement and implementation has not yet commenced. Consequently, awareness and control programs related to AMR have failed to reach the grassroots level, and the crucial aspect of addressing gender has yet to receive the necessary attention.
Dr Dulal stresses the importance of government endorsement and active implementation of that plan. There is a need to progress with a focus on the five key pillars, he says: awareness, surveillance, infection prevention and control (IPC), rational research innovation, and coordination and engagement.