Nepal’s maternal mortality decline paradox

While health experts applaud Nepal’s declining maternal mortality ratio (MMR) in recent years, they say this gain is unsustainable if the country does not address its lack of qualified health staff, especially midwives, to keep women in childbirth alive.

Between 1996 and 2006, Nepal nearly halved its MMR, from 539 deaths per 100,000 live births, to 281, according to the latest Demographic and Health Survey (DHS). A 2012 UN report estimated the 2010 MMR at 170. (The range of uncertainty went from a low estimate of 100 to a high estimate of 290.)

Observed declines since the early 1990s make Nepal, together with Bangladesh, the most recent “success story”, comparable to countries like Malaysia, Thailand and Cuba that gained ground decades earlier, Julia Hussein, lead author of a 2011 medical appraisal of Nepal’s MMR reduction, told IRIN.

Experts are still deciphering the past decade’s declining MMR in Nepal.

“The problem we have is that the data we need to identify causes of maternal mortality reduction are not actually there,” said Hussein, who, rather, looked for changes associated with the decline. “The paradox in Nepal is that skilled birth care is still very low, yet maternal mortality is decreasing.”

Though there is generally a positive association between increasing rates of births attended by skilled birth attendants (SBAs) and a falling MMR, this correlation is not very strong for countries in sub-Saharan Africa and Asia, Hussein told IRIN.

Nepal’s success is explained by many factors, said Kabiraj Khanal, the Ministry of Health and Population’s under-secretary. “Maternal mortality has not reduced because of just one reason - different interventions have been implemented simultaneously.”

What’s working?

Top reasons identified by health practitioners were fertility declines, societal changes and government programmes to enhance both supply and demand of maternal care.

Women now give birth on average to 2.6 children versus 4.6 children 15 years ago, a decline Khanal credited to social and economic developments, including male partners migrating for work.

“Nepal has quite a strong family planning programme,” added Hussein. Half the women surveyed in the 2011 DHS reported using contraception. But, she added: “Fertility reduction can only improve maternal mortality levels to a certain extent, because eventually you are going to reach a point where women still want to have babies.”

Hussein found improvements in women’s education, empowerment, wealth, and living standards were also strongly associated with a declining MMR. Nepal’s Human Development Index, which assesses a population’s well-being by measuring poverty, education and life expectancy, increased from 0.34 in 1990 to 0.46 in 2012; female literacy jumped from 35 percent in 2001 to 57 percent a decade later.

“On the demand-side, people’s health-seeking behaviour has changed, and on the supply side, health facilities, hospitals, services, and health workforce have increased,” said Ganga Shakya, maternal and neonatal health adviser for the UK-funded government technical assistance project, Nepal Health Sector Support Programme.

Under a Safe Motherhood Programme, in 2009 the government started offering free deliveries and travel stipends of US$5.80, $11.50, and $17.30 for women to reach accredited birthing facilities in plain, hilly, and mountainous districts, respectively. Women also get close to $5 if they seek health care pre-delivery at least four times, in line with international health recommendations.

Health facilities receive cash to procure drugs and other materials for deliveries - $11 for vaginal births, $34 for managing obstetric complications and $80 for Caesareans.

In the absence of professional midwives, pregnant women in Nepal depend on 4,000 SBAs certified in certain core midwifery skills, and counselling provided by 52,000 female community health volunteers who are part of a government initiative launched in 1988 to fight maternal and neonatal (infants 28 days and younger) deaths.

“They [volunteers] are often seen as doctors in the remote villages… They are… constantly in touch with the poorest women who often have difficulty making long journeys to the hospitals,” said Jung Shah, a hospital director in the mid-western region’s main government health centre.

The percentage of births assisted at delivery by someone formally trained in birthing has almost doubled in the last five years to 36 percent in 2011.

Delivery assistance by an SBA in rural areas has more than doubled in the last five years, from 14 percent to 32 percent, though pregnancy in the mountains is still mostly a solitary family affair, with as few as 15 percent of women getting outside trained assistance during childbirth.

And more births are taking place in a health facility - from 18 percent in 2006 to 35 percent in 2011. In the same period, districts with at least one facility performing Caesarean sections rose from 30 to more than 50 districts, with a more drastic increase in centres offering 24-hour delivery services - from 300 to 1,200. Abortion was legalized in 2002, with 300 sites now registered nationwide.

“We are focusing on whatever women die from,” said Shilu Aryal, obstetrics and gynaecology (OB-GYN) consultant at the Family Health Division in the Health and Population Ministry.

When postpartum haemorrhage was identified as the biggest maternal killer, female volunteers distributed tablets of misoprostal (a drug that causes the uterus to contract and lessens blood loss) to women’s homes to reduce the risk of excessive bleeding after home deliveries.

The Health Ministry also recently decided to provide blood transfusions to pregnant mothers for free, in addition to no-cost oxytocin injections (to stop bleeding) at health facilities since 2002.

What needs improvement?

While the country is on track to achieve its Millennium Development Goal of cutting MMR by three-quarters of its 1990 level (down to 134 deaths per 100,000 live births), the government is cautious.

“We will eventually reach a plateau, after which it will be difficult to further reduce our maternal mortality. At that point, we will need people skilled in midwifery,” said Senendra Raj Upreti, director of the Family Health Division.

In 2006 Nepal developed a national policy on SBAs to address the fatally low numbers of pregnancies aided by SBAs, which back then stood at 18 percent. The policy proposed measures to improve midwifery skills among nurses, doctors and auxiliary nurse midwives, (the latter receive less education and practical training than midwives). The policy foresaw providing at least three years of training to a new group of professional midwives.

Since then, the UN Population Fund (UNFPA) has drafted a Bachelor in Midwifery curriculum for Nepal and studied how to incorporate it into national academic institutions.

“Professional midwives can prevent up to 90 percent of maternal deaths where they are authorized to practice,” suggested a 2012 UNFPA study. “Investing in midwives has been identified as the quickest and the most cost-effective solution for scale-up in skilled attendance at all births” - an indicator Nepal still lags far behind in. Its goal is for 60 percent of women to give birth with the help of a skilled practitioner; the most recently recorded rate is 36 percent.

Last month, the government set up a task force on midwifery education whose chair hopes to enrol the country’s first midwives by 2014.

Health care staffing

But lack of midwives is only a small part of the larger recruitment challenge facing Nepal, especially in most remote areas where health staff are reluctant to relocate.

Neither the distribution of health workers nor their total count has budged in the past 15 years, said Aryal, the OB-GYN consultant. “[In Nepal] 15 years ago, there were 10 million people, now we have reached 30 million, but we have the same number of people working in the hospitals.”

A 2011-2015 government health human resources plan pinpointed this disparity; in the last decade the population grew by 45 percent while public health staffing increased by only 3 percent.

Nepal has 0.29 health workers for every 1,000 people, a small fraction of the World Health Organization recommended 2.3 needed to offer basic lifesaving care, including vaccinations for every 1,000 residents.

And while the private sector has expanded significantly, those facilities are mostly in urban areas (in a country where some 80 percent of the population lives in rural areas) and are unaffordable to the poor.

Nepal needs to improve its referral system in remote areas to transport women with medical complications, said Asha Pun, maternal and neonatal health specialist at the UN Children’s Fund office in Kathmandu.

Family planning access is still perilously out of reach for youths, said UNFPA’s former deputy representative in Nepal, Geetha Rana. Twenty-seven percent of married women nationwide have an unmet need for family planning, increasing to 42 percent if only counting women aged 15-19 - significant given half of all females in Nepal are married by age 18.

Hussein, the researcher, suggested improving Nepal’s death registration to understand what has - and has not - worked in slashing maternal deaths. “Things are reducing, but you can only learn lessons from it if you set up data collection systems that allow you to explain it.”

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