Nepal: Focus of Maternal and Child Services Nepalese women constitute slightly more than half of the country's total population of 25.7 million. According to Ministry of Health estimates, pregnancy-related complications.... Read More >>   Feedback We shall be grateful, if you send us your opinion, suggestions or comments to this site. Feedback Form   Check Your Email Email Password     NEPAL: Focus on Maternal and Child Health Services THE SCALE OF THE PROBLEM Nepalese women constitute slightly more than half of the country's total population of 25.7 million. According to Ministry of Health estimates, pregnancy-related complications kill over 4,500 women every year in Nepal. More than 1 in every 200 pregnant women in Nepal dies giving birth. Each day in Nepal, 12 mothers and 75 new-born babies die in childbirth. Most of the mothers die of severe bleeding, a complication that can be treated even in basic health centers. Most of the deaths occur in rural areas, where access to health services and health personnel is severely limited. Although many factors contribute to maternal mortality, health experts from around the world have identified three main factors for the terrible mortality rate, referring to them as ‘the three D’s.’ They list them as delay in taking the decision to seek medical assistance, delay in accessing the appropriate care and the delay of care at health centers. Of which they identified that the lack of access to a trained midwife as being at the top of the list. Moreover, a lack of access to medical care, poor health education and the low status of women are the main causes in the context of Nepal. Only when a large proportion of women are cared for by skilled attendants can this mortality rate drop significantly. At present, only 13% of births in Nepal are attended by a trained health care worker of any kind, and for the poorest 20% of families, this figure is only 3%. Around 900,000 pregnancies are expected this year and statistics indicate just under 129,000 (14.3%) will develop life-threatening complications, according to data supplied by the national Support for Safe Motherhood Programme (SSMP) run by the government and funded by the UK Department for International Development (DFID). However, maternal mortality in Nepal is high relative to developed countries. A 1997 government report estimated the maternal mortality ratio (MMR), which is an indicator of the over-all health of a population, stands at 540 deaths per 100,000 births in Nepal. This ranks among the highest in the world. In comparison, MMR is 90 in Sri Lanka and just 8 per 100,000 in the U.S. The Human Development Report for 2004 by the United Nations Development Programme (UNDP) estimates the figure to be substantially higher at 740 per 100,000 births. A third report by the Population Reference Bureau, a US-based NGO, places the figure even higher still at 830 per 100,000 births. Similarly, the neonatal morbidity and morality (39 per 1000 live births) rates remain high. In Nepal, it does not seem that the maternity mortality as a public health indicator but more as a human rights and gender discrimination issue. HOME BIRTHS In Nepal, almost 90 per cent of births take place at home with the assistance of relatives, friends and untrained midwives, according to official statistics. Only eleven per cent are attended by properly trained medical staff. In the absence of trained midwives, many women suffer from prolonged labour and complications caused by a retained placenta. According to statistics, a large number of them die from subsequent bleeding or ‘post-partum haemorrhage’ amounting to about 46 percent of maternal deaths. REASONS FOR DELAYS The problems arise when family members in rural areas don’t take immediate action to get the woman to hospital, according to some health experts. The low value of the daughter-in-law in Nepalese culture and cash problems lead to the delay. According to one recent report from the eastern Morang district, a woman in her fifth pregnancy and under medical supervision, suffered from internal bleeding after her uterus burst. Family members refused to donate blood when asked by the doctor. “If she dies then that is her fate,” the family members, including her husband, told the doctor. “I will feel weak if I give her my blood,” said the husband. In less than an hour, she was dead. “This is an example of how low women are valued and how they are so grossly discriminated [against],” health worker Upreti explained. She has travelled extensively in the most remote areas to treat pregnant women. “She did not die due to a lack of doctors or medicines,” said Upreti. EFFORTS TO REDUCE THE PROBLEM Although the global initiative to reduce maternal mortality and promote safe motherhood practices started in the mid 1980s, Nepal was slow to start any national initiative despite having one of the highest death rates. It was only after the Cairo conference on population and development that Nepal finally launched the national safe motherhood plan of action. International pressure following the national health survey of 1996 pushed the government of Nepal into initiating a programme of action. Nepal has a long way to go to achieve the Millennium Development Goal of achieving a 90 per cent attendance at birth by trained personnel and reducing the maternity mortality ratio to 200 per 100,000 births by 2015. By recognizing these challenges, the Family Health Division is beginning to replicate the Sri Lankan model by initially training professional health workers in the skills needed. It plans to focus on the establishment of numerous birthing centres staffed by 6,000 midwives both in the rural countryside and in Nepal’s mountains and hills. However, according to SSMP, over 700 trained midwives are needed only in 16 mountain districts. To fulfill these commitments the Ministry of Health developed the National Policy on Skilled Birth Attendants (SBA) on June, 2006 within the National Safe Motherhood Policy 1998 that placed emphasis on: Strengthening maternity care, including family planning services at all levels of health service delivery including the community. The National Safe Motherhood Plan 2002-2017 developed a long-term vision to scale up the coverage of maternal and newborn health care at all levels of health care delivery system. Strengthening the technical capacity of maternal health care providers at all levels of the health care system through training. The National Safe Motherhood Training Strategy-2002 focused on strengthening pre-service and in-service training institutions to ensure that all health providers have appropriate skills according to the national Reproductive Health Clinical Standard 1998. Deploying and providing appropriate support and personnel for each level of maternity services was an identified objective. The importance of appropriate human resource as an essential component of ensuring quality maternal health services was reiterated in the Nepal Strategic Plan for Human Resources for Health 2003-2017. This SBA Policy addresses the gaps identified by the National Health Policy-1991 and Nepal Health Sector Programme-Implementation Plan (NHSP-IP) 2004-2009. The SBA Policy is linked to other national policies and strategies. This SBA Policy is concurrence with the NSHP-IP 2004-2009 with output one and output seven.