More than 300,000 women die from childbirth or as a result of complications of pregnancy every year. This equates to approximately 800 women dying from preventable causes related to pregnancy and childbirth every day. The overwhelming number of maternal deaths occurs in developing countries which are around 239 for every 100,000 live births. This is about 20 times higher than that of developed regions which is 12. Sub-Saharan Africa accounts for more than half of these deaths while South Asia experiences almost one-third of them Nepal is a one of the South Asian countries with a very high maternal mortality ratios. Maternal mortality is one of the leading causes of death for women of reproductive age in Nepal, most of which occur due to direct obstetric complications at the time of birth and during the postnatal period.
How many women die in childbirth in Nepal?
According to Nepal Demographic Health Survey, the current estimated maternal mortality ratio (MMR) of Nepal is 259 per 100,000 live births. One in four (24%) mothers loss their life during or after childbirth and two in five (19%) in the postnatal period from the total number of maternal deaths.
Where do the most maternal deaths occur in Nepal?
The overwhelming majority of maternal deaths occur in rural, poverty ridden areas where healthcare services are often inadequate or inaccessible. Even in places with access to health services, there is a severe shortage of trained medical staff. The people who are marginalized in terms of geography, economy, ethnicity, and education are less likely to have institutional delivery. There are clear disparities according to geographical and socio-economic perspectives, for example, the lowest percentage of institutional delivery than the national average was observed in Karnali province (38%) and Province 2 (43%).
Why are women still dying in Nepal?
There are a number of reasons, and these include inadequate health care, lack of family planning services, long distances to health facilities, and early marriage, which leads young girls to give birth before their bodies are ready. These factors are further rooted in poverty, illiteracy, patriarchy, gender inequality and culture. Obstetric hemorrhage and hypertensive disorder of pregnancy take the most lives of mothers while embolism, unsafe abortion and infection after childbirth all contribute.
What is the progress made so far?
Nepal has made impressive progress in reducing its maternal mortality, from 850 maternal deaths per one hundred thousand live births in 1990 to 239 in 2016. National average rate of institutional delivery increased eight-fold from 7% in 1990 among all women of reproductive age which was 59 per cent in 2016. This progress can be largely attributed to community level interventions. In order to sustain this momentum, continued investments and efforts must be made to ensure availability and accessibility of adequate quality of maternal health care.
Sustainable Development Goals and Maternal Health
Nepal has made a commitment to achieve the Sustainable Development Goals (SDG) target 3.1 of reducing the global MMR to less than 70 maternal deaths per 100,000 live births by 2030. In order to achieve this ambitious goal, Nepal will need to reduce its MMR every year by at least 7.5% while addressing severe inequities in maternal health access and utilization.
The way forward
Despite the substantial progress in improving maternal health care access and utilization in Nepal, disparities remain based on women’s socioeconomic status, literacy level and place of residence. The majority of these deaths are preventable. Therefore, Nepal needs to accelerate its efforts to address the gaps in the coverage and qualityof maternal health care to end maternal deaths.
Universal coverage with high quality care in all essential interventions across the continuum of care is required for reducing all preventable maternal deaths. Maternal deaths can be reduced by preventing unwanted pregnancies through effective family planning programs, ensuring high coverage of quality care at birth and during the postnatal period, provision of emergency obstetric care services and availability of skilled health care providers.
Promoting family planning
The universal access to family planning services is key to reducing maternal mortality. Nepal needs to adopt strategies to scale up the accessibility and availability of family planning services by supporting satellite clinics, ‘micro-planning’ and mapping at district level, and capacity building of health workers in the use of long-acting family planning methods. It is essential to strengthen the supply chain, avoid stock-outs of family planning commodities and make these available in the targeted health facilities. Since young adolescents are at a higher risk of complications and death as a result of pregnancy, mass media campaigns must be employed to increase access to information on sexual and reproductive health and family planning.
Supporting midwifery in Nepal
While Nepal has reduced its MMR by half since 1990, this gain will be hard to sustain unless there are efforts to improve the quality of the services and the health care providers, especially midwives. Approximately 2/3 of all maternal and newborn deaths could be prevented with the assistance of well trained midwives. Therefore, there need to be efforts to support midwifery education and training and formulate standard midwifery guides.
Enhancing institutional delivery
There is a need to encourage care seeking behavior with a special emphasis on pregnant women and young couples to promote antenatal and postnatal visits along with institutional delivery. Socio-cultural barriers that view childbirth as a normal life event encouraging home births need to be addressed through community awareness. Maternal and Child Health (MCH) Wings must be established at high caseload facilities to improve the quality of care provided to mothers and children. Birthing centers must be sufficiently equipped with proper supplies, medications and adequately staffed with skilled service providers. Referral transport for pregnant women must be provided as per their local needs like emergency ambulance services at the provincial and local level to tackle the issue of accessibility so as to facilitate institutional delivery.
Strengthening and capacity-building of peripheral health systems and health professionals.
The local governments must be extended with support to map out underserved areas in terms of maternal health service utilization and develop locally appropriate action plan to cover them. A slew of measures can be employed to enhance the availability and improve retention of rural health providers particularly in hard-to-serve areas for instance through special incentives. Investments must be secured for capacity building of these health care providers in basic and comprehensive obstetric care in providing high quality obstetric services.
Preventing early marriage
One of the most effective ways to lower maternal mortality is delaying pregnancy. Young girls’ bodies are not ready for childbirth and succumb to the complications of pregnancy and childbirth. An estimated 15 % of young women give birth before the age of 18. For many of these adolescents, pregnancy and childbirth are neither planned, nor wanted. We need to ensure that girls who are already married have access to family planning. We also need to make sure that policy and legal frameworks are supportive to put an end to early marriage.
Ensuring universal access to reproductive healthcare will require the availability of skilled health human resources, and an enabling environment (including essential drugs and devices), health institutions on strategic location and community participation. A multi-sectoral collective effort is crucial in order to address the equity gaps in maternal health and accelerate pr ogress.