Suicide and deliberate self-harm among women in Nepal: a scoping review | BMC Women’s Health

The results from this review provide an overview of the information about suicide and DSH among women in Nepal based on available literature. Findings from this study suggest that suicide and DSH among women is a worrisome public health problem in Nepal due to various underlying socio-cultural, economic and environmental factors. Based on our review, although suicide can occur at any age during the lifespan of an individual [1], suicide and DSH attempts are higher among younger females aged between 15–35 years compared to older ones [11, 15,16,17,18]. According to the MMMS (2008–2009), suicide stood out as the single leading cause of death among WRA in Nepal with 63% of suicide deaths occurring among women between 15–29 years [5]. Various studies conducted on DSH also highlighted higher DSH among married women aged between 15–30 years [11, 15, 17, 20, 21]. This apparently highlights the severity of suicide and DSH as a major health challenge with young women observed to be more vulnerable to suicide in comparison to older women.

These findings are similar to suicide among women in India where young women below the age of 30 are at higher risk of committing suicide [26]. Suicide among women in Asia may well be related to lack of the awareness of women’s rights, women’s dependency on men, and women’s social status. As women in Asian countries often have a subordinate position, they may experience high levels of stress which are intensified by family hierarchy and dynamics in societies [26]. Younger individuals are not sufficiently mature to handle stressors in general, and young women in Asia, including Nepal, face higher social, emotional or financial dependency on their families and husbands, which makes them vulnerable to such stressors with no one to turn to, potentially leading them towards DSH or suicide as a cry for help or a perceived route of escape. The reviewed literature identified young women to be more vulnerable to suicide compared to older women indicating age as a risk factor. Nonetheless, the studies do not explore in depth the conditions and reason behind it, untangling whether it is the younger age or rather the conditions and circumstances in the given age which could be the actual risk factor.

In most of our reviewed studies the majority of the suicide and DSH victims were found to be married (i.e., up to 84% in a review of police records) [5, 19]. In Nepal, as in other South Asian Countries, it is common for women to get married at a young age through arranged marriages with often a large age gap between husband and wife. As divorce is culturally demeaning and highly stigmatized, Nepalese women will stay married even after enduring abuse in an unhappy marriage [19]. Young women’s household decision-making capability and the challenges they face in dealing with the distribution of power and the dynamics within the in-law family are shaped by socio-cultural factors. This in turn not only increases their vulnerability towards being overburdened with domestic responsibilities and psychological abuse, but also physical violence [19]. Along with this, married South Asian women may also endure other pressures such as young motherhood, low social status and economic dependency making them susceptible to suicidal ideation and acts [27]. Nepalese women’s lower status in the family and society are reinforced by religious, cultural and social norms which could act as triggers of violence [28]. Therefore, in most South Asian countries, including Nepal, marital status does not appear to be a protective factor but rather a condition that seems to expose them to abuse, resulting in increased risk of suicide. The reviewed studies highlight being married as an underlying reason for suicide among women. However, the studies do not provide any clarity on whether it is the marital status itself or the stressful encounters endured in one’s married life which makes them vulnerable to suicide.

Although married women are at higher risk of suicide in Nepal, suicide among unmarried women is also on the rise. According to the MMMS 2008/09 even though suicide deaths were mostly persistent among married WRA, reflecting the larger number of married women in the society, suicide deaths accounted for a larger proportion in unmarried (25%) WRA than the married women (15%) WRA [5]. Traditionally, Nepal’s patriarchal and conservative perspective regarding marriage restricts youths’ involvement in their own life partner selection [29]. However, in recent times, family pressure on young unmarried girls for marrying the men chosen by parent’s agreement without considering their preference, results in a sense of loss of control over their own lives that can trigger suicidal attempts as the only option to get heard [19]. Other contributing reasons might be failed love relationships, lack of marriage building stress in the family, and pregnancy before marriage [19].

In our review, poisoning was the most common method for suicide and DSH among women with most of the suicide/ DSH victims consuming pesticide (commonly organophosphates) [11, 13, 15, 16], followed by hanging [12, 18, 24]. As women may attempt suicide/DSH as a means of expressing their need for attention and assistance [19], it could explain the use of less lethal methods for suicide, which is similar to observations across the globe. It seems easy access to pesticides and ropes and scarves [15, 16, 21] facilitates these methods of suicide.

Poisoning also offers the possibility of dosing intake, making it a preferred method when the intent is to alert the family of one’s distress without terminating one’s life. Furthermore, lack of understanding about the lethality of a given method may come into play as well [19]. This coincides with studies conducted in Sri Lanka that reported on women attempting suicide by ingesting pesticides or setting themselves on fire, with the intent to threaten the family members, but unaware of the risks involved leading towards lifelong irreversible impairment [30].

In the majority of studies reviewed, abuse, interpersonal conflicts, marital disputes, relationship problems and adjustment problems were the most common psychosocial factors leading to suicide/DSH among Nepalese women [10, 11, 13, 18, 20, 21, 24, 25]. While in-laws were found to be mostly responsible for emotional or physical abuse, the most common perpetrators of physical abuse were husbands [19, 25]. Findings from Nepal Demographic and Health Survey 2016 indicated among WRA, 22% of women and 26% of ever married women had experienced physical and spousal violence respectively at least once in their lifetime [31]. In Nepal, 60% of women have not sought help or disclosed to anyone the domestic violence they experienced in their lifetime [31]. Many Asian societies culturally disapprove discussion of domestic problems outside of the family, thus discouraging women from reporting abuse due to fear of public humiliation, shame and further retribution from their spouse [32]. As a result, not seeking any sort of assistance from any source leads to internalizing stresses and increasing the risk of suicide ideation, DSH and suicidal attempts.

Among married women interpersonal conflicts with in-laws and marital disputes between spouses were generally related to being married at a very young age, accusations of love affairs, husbands alleged second marriage or extramarital affairs and alcohol abuse leading to increased stress and violence [13, 14, 19, 25]. Nepalese women often indicate a husband’s alcohol abuse as an attribute to spousal violence and marital disputes [25, 33]. Whereas, among the unmarried adolescent women, interpersonal conflicts with parents were mostly over relationship problems and romantic partners, and academic failures [10, 11, 13, 14, 18, 20, 21, 25]. Lack of liberal perception regarding love relationships and inter-caste marriage, and non-acceptance of such relationships may lead to interpersonal disputes among young women and their families and/or their romantic partners. Academic failure is also a trigger for suicide and suicidal attempts among adolescent women [19]. A study on poisoning cases in Dhulikhel hospital, where the majority of cases were female, 16.67% consumed poison due to failure in examinations [34]. Further, the police records found the rate of suicide among youth to be higher during the School Leaving Exam (SLC/ Standard 10th grade exam) and after the publication of its results [19].

Financial issues such as unpaid dowry and loans were found to be the economic factors resulting in suicide and DSH among women [13, 25]. Although women devote a lot to household wellbeing and income, they are not granted economic value or reward making them financially dependent and inferior to their husbands [19, 31]. Where women are financially dependent, it can be assumed that financial constraints due to husband’s alcohol abuse, and unpaid debts pose economic stressors. Such economic stressors usually take form of arguments, conflicts and abuse between spouses [25] and may result in suicide attempts or DSH among women.

Suicide is more closely connected to impulsivity than deliberate attempts or mental illness in Nepalese society [25]. A sense of hopelessness and despair relevant to domestic violence and social shame based on moral judgment from society appears to leave women to believe they have no other option than suicide as the only way out [25]. These findings are consistent with studies in India, where women consider suicide as their only option [35, 36]. This illustrated how emotional and social stress is internalized to act as a psychological stressor for impulsive suicidal attempts and DSH among women.

Mental health disorders, commonly mood disorders (such as depression) and adjustment disorder along with substance abuse were found to be relevant to suicide/DSH among women [10, 11, 13, 18, 21]. Mental illness could be interlinked with socio-economic factors of suicide, since poor mental health is an outcome of social determinants like poverty, social exclusion, marital problems, unemployment, low socio-economic status and stressful events [37, 38]. The 2008/09 MMMS reported that mental health problems were a major underlying factor due to repercussion of social determinants and demonstrated how social norms, poverty and poor access to healthcare overlap with poor mental health. Some cases in the study also highlighted how issues related to marriage (e.g., early marriage, or being deprived of love marriage) lead to depression [19].

Psychosocial and economic factors such as interpersonal conflicts, marital disputes, abuse, relationship problems, adjustment issues and financial problems; and mental health conditions were highlighted as factors associated with suicide and DSH among the majority of the studies reviewed. These present proximal factors related to suicide among women. Only a few studies were found to superficially explore factors such as poverty, social exclusion, gender inequity, and education which may be the root causes of suicide and subtly touched upon traditional, cultural and patriarchal systems in Nepal. For example Pradhan et al. pointed out that problems related to marital, husband/family relationship are related to women’s status and gender based violence which is influenced by the Nepalese socio-cultural gender norms and gender inequality [19].

The question arises as to why root causes of suicide receive limited attention. Is it due to the complexity of the issues involved and challenges presented when attempting to investigate these factors? Further, most of the studies reviewed took place in hospital settings, demonstrating the need for suicide studies focusing on community settings. Grassroot studies should embody a dialectical interface between women, partners and family and their socio-cultural environment to enhance insight in the dynamics of partner and family relationships and disentangle pathways in coping with stressors associated with suicide among young women in Nepal, informing future community-level suicide prevention efforts.

Addressing the emerging problem of suicide among women, calls for multidimensional approaches aimed at changing the socio-cultural environment and interpersonal relationships. Such approaches require policy responses and collaborations among government, civil society and communities. However, societal changes take time and resolution may unfold over a generation. While acknowledging the need for multidimensional approaches to suicide prevention, it became clear from our review that sociocultural and economic contexts shape family and marital relationships, impact personal mental wellbeing of Nepalese women and fuel suicidal attempts and DSH. Hence, grassroots study approaches involving husbands or partners and families could facilitate a deeper understanding of factors associated with suicide among women and be instrumental in exploring pathways for suicide prevention at community level.

There are some limitations in study design and analysis that could affect our findings: (i) only English publications were included, and information reviewed was limited to sources accessible via search engines and public domains; (ii) the study did not assess religious, ethnic and educational aspects as potential factors associated with suicide and DSH among women in Nepal due to paucity of information.

The study also possesses an important methodological strength: data analysis comes from reliable, and peer- reviewed journal publications and documents thus limiting the chances of using unreliable data or information in the analysis.