Suicide and deliberate self-harm among women in Nepal: a scoping review
Sarina Pradhan Kasaju, Anja Krumeich, Marc Van der Putten
BMC Women's Health · 2021 · DOI: 10.1186/s12905-021-01547-3
Countries: Nepal
What Was Studied
This scoping review followed Arksey and O'Malley's six-step methodological framework to map existing peer-reviewed and grey literature on suicide and deliberate self-harm (DSH) among women in Nepal. A Boolean search of PubMed and Google Scholar (July 2019) combined with reference-list snowballing identified 9,256 records; after removing duplicates and screening titles, abstracts and full texts, 18 studies were included — 15 peer-reviewed articles (mostly retrospective hospital case series and cross-sectional studies, one mixed-methods and two psychological-autopsy studies) and 3 grey-literature reports (including the government's Maternal Mortality and Morbidity Study). A single reviewer screened studies, calibrated against two co-authors, with a Holsti's coefficient of 0.9 on a 10% sample. The review mapped patterns by age, marital status, means of suicide, and psychosocial, economic and mental-health contributing factors.
What They Found
Suicide accounted for the cause of death in ~16% of the 1,496 deaths recorded among women of reproductive age (WRA, 15–49) in the 2008/09 Maternal Mortality and Morbidity Study (MMMS) — up from 10% in the 1998/99 MMMS — meaning suicide is Nepal's single leading cause of death among WRA; this is a share of WRA deaths, not a population incidence rate (police data from 2009/2010 separately showed the suicide rate peaking at 7.4 per 100,000 among women aged 20–24). Some 63% of suicide deaths occurred among women aged 15–29. Suicide accounted for a higher share of all deaths among unmarried women of reproductive age (25% of 197 deaths) than among married women of reproductive age (15% of 1,191 deaths) in the 2008/09 MMMS, even though married women made up the numerical majority of suicide/DSH cases across individual studies (73% of WRA suicide deaths in the 2008/09 MMMS; up to 84.1% of all ages in 2003–2011 police records). Poisoning (commonly pesticides) was the most common method, reported in 88% of studies, followed by hanging (16%). In a psychological autopsy of 2013–2015 police-recorded suicides, 61.1% of female decedents had experienced physical abuse within three months of their death; separately, NDHS 2016 found 22% of Nepali women (26% of ever-married women) had experienced physical or spousal violence in their lifetime, and 60% had never disclosed it. Only 2 of the 18 included studies examined poverty, and just 1 examined social exclusion, gender inequity and education as suicide risk factors.
What This Means for Nepal
This review is a scoping tool, not a pooled meta-analysis — it maps where evidence exists (hospital-based, proximate psychosocial factors like marital abuse and financial stress) and where it is thin (only 2 of 18 studies touch poverty; caste/ethnicity and education were not assessable due to data paucity). For Nepal's Ministry of Health and Population, whose own suicide indicators this review calls unreliable, the priority is building the national suicide surveillance system that does not currently exist — for example by adding a validated verbal-autopsy suicide module to the next Nepal Demographic and Health Survey, following the MMMS model this review relies on. Second, because most evidence comes from urban tertiary hospitals (Kathmandu, Dharan, Chitwan), Nepal's mhGAP scale-up and FCHV-led community outreach should be extended to screen for domestic-abuse-linked psychosocial distress in rural and community settings, where this review found the evidence base is almost absent. Third, the review's finding that root causes — patriarchy, gender inequity, poverty — remain "superficially explored" strengthens the case for finally enacting Nepal's long-stalled Mental Health Act (still absent despite the 2020 Mental Health Strategy) to create a legal mandate and dedicated financing for women-focused suicide prevention programming.
Contextualisation
Nepal has no national suicide surveillance system, and this review's own key source — the 2008/09 Maternal Mortality and Morbidity Study (MMMS) — confirms that Ministry of Health and Population suicide indicators are unreliable, a gap corroborated by NHPL's Nepal knowledge base. The widely-cited "16 per 100,000" figure is a common misreading: the review reports suicide caused ~16% of the 1,496 deaths recorded among women of reproductive age in the 2008/09 MMMS — a share of deaths, not a population rate; WHO's actual age-standardised suicide rate for Nepal is ~9.8 per 100,000 (2019). With psychiatrists at only ~0.17–0.22 per 100,000, a >90% mental health treatment gap, and no Mental Health Act ever enacted despite the 2020 Mental Health Strategy, this review's mapping of proximate drivers — spousal abuse, marital disputes, financial stress — is directly relevant to Nepal's 2026 mental-health integration priorities (mhGAP scale-up in primary care).