Understanding safe water-carrying practices during pregnancy and postpartum: A mixed-methods study in Nepal

Daily carrying of heavy loads of domestic water, especially during pregnancy and postpartum, bears a threat to maternal health in low-income countries. Using an extended health action process approach (HAPA), we examined women's reasons for and psychosocial determinants of safe water-carrying during pregnancy and postpartum. In a mixed-methods study, trained local interviewers conducted 1001 quantitative interviews with women of reproductive age (n = 921 analyzed) and 21 qualitative interviews with women of reproductive age, in-laws, and spouses in rural Nepal. We analyzed the quantitative data with generalized estimating equations to model the HAPA-based psychosocial determinants of avoiding water-carrying during pregnancy and postpartum. Subjective perspectives were investigated with thematic analysis. Outcome expectancies (B = 0.24), self-efficacy (B = 0.20), and injunctive norms (B = 0.23) were significantly associated with the intention to avoid water-carrying. Self-efficacy (B = 0.36) and instrumental support (B = 0.05) are related to behavior (all p < 0.05). Women explained water-carrying during pregnancy by a lack of family support, a shift of health decision-making power to in-laws, and low behavioral control. Overall, the necessity of water, family decision-making structures, and low support make it difficult for women to discontinue water-carrying. Additionally to infrastructural improvements, behavioral interventions may increase women's self-efficacy for safe water-carrying (e.g. reducing weight) and social support.