Saving more mothers and babies

How Nepal can revive stalled progress in improving maternal and child health

A smile on a mother’s face in Mahottari seeing her baby survive. She was not so lucky with her previous baby, who died during childbirth. Madhesh has one of the highest maternal and neonatal mortalities compared to other provinces. Photo: NARESH NEWAR

Over the last two decades, Nepal has made notable progress in maternal and neonatal healthcare. The maternal mortality ratio (MMR) has declined from 536 per 100,000 live births in 1996 to 151 by 2021.

Driving this process were the country’s Safe Motherhood policy, an increase in skilled healthcare providers, free delivery services for expectant mothers, incentive schemes for antenatal care, as well as postnatal visits.

Other measures, such as birth preparedness packages along with systematic planning for managing potential complications during childbirth, amplified these achievements. 

There has been a remarkable rise in institutional deliveries, an increase in antenatal visits, and an impressive 70% of women receiving postpartum care from healthcare providers within the first two days after giving birth.

Quality improvement initiatives such as the Maternal and Perinatal Death Review, minimum health facility assessment standards, routine clinical monitoring, and supportive onsite supervision visits, have been outlined in policy documents and guidelines to elevate the overall quality of care. 

However, it is when analysing province-wise MMR. that we still see significant disparities. Maternal deaths are still high in Lumbini Province (207 per 100,000 live births) and Karnali (172). The MMR in Bagmati Province (98) correlates with better figures for higher education, awareness and access to health service and providers.

In contrast, 83% of women in Karnali face challenges in seeking medical care, primarily due to financial constraints and long distance to healthcare facilities.

Half of the maternal deaths in Nepal are of mothers within the age groups of 15-34. Despite the legal marriage age being 20, child marriage is still widespread and contributes to the highest number of pregnancy-related deaths. 

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The median age of marriage in Nepal is 18.3 years, with the lowest median age in Madhes province at 16.6 years and the highest in Bagmati province at 19.9 years. The Muslim community reports the lowest at 16.5 years, while the Janajati and Brahmin/Chettri communities have generally higher median ages for marriage.

In Madhes and Sudur Paschim Provinces early marriages among girls under 15 contribute to heightened adolescent mortality, mainly due to difficulties accessing timely health facilities. Disparities persist among ethnic groups, particularly among doubly marginalised Madhesi Muslims, who face high mortality rates due to early marriages.

Health facility deliveries have improved from 10% in 2001 to 79% in 2021. But again, progress is uneven and these disparities need to be overcome to meet the UN’s Sustainable Development Goals (SDGs) target of 90% institutional delivery rate by 2030.

Wealth inequality and provincial variations, especially in Madhes, pose challenges that need nuanced understanding of women’s reluctance to seek health services. 

Despite Nepal’s success in maintaining population growth close to replacement levels, the total fertility rate (TFR) is significantly higher among those without formal education. The proportion of postpartum family planning uptake is also lowest in Madhes and Sudur Paschim at only 0.2%.

Breastfeeding is in decline, with less than three out of five mothers following recommended practices. Regional variations highlight the need for targeted interventions, particularly in provinces like Bagmati, where breastfeeding rates are lower among well-educated city dwellers. 

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Anemia persists as another risk factor, with Madhes Province again carrying the highest burden.

Comparing Nepal with Bangladesh, India, and Pakistan shows that we are doing better in under-five and infant mortality rates. Nepal’s institutional delivery rate surpasses Bangladesh, but lags slightly behind India.

Even so, alarming disparities persist in neonatal and maternal mortality rates within disadvantaged groups, reflecting inadequate coverage of routine maternal and neonatal health visits and suboptimal care. 

This points to both limited access to recommended interventions for disadvantaged women and potential inefficiencies in delivering crucial interventions during routine these visits.

Nepal should prioritise rural pockets of the country and employ a comprehensive strategy that includes delivering antenatal care through primary health care outreach, home visits, distributing essential medicines, vaccinations, and identifying appropriate health facilities for birth preparedness.

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The quality of antenatal care must be improved by talking about nutrition with pregnant women and families, emphasising awareness of danger signs that necessitate timely health facility visits, and ensuring local governments can efficiently refer complicated cases, with airlifting as a viable option for emergencies.

Adolescent Sexual Reproductive Health with a targeted focus in provinces with early marriages and childbirths combined with education, awareness, and easy access to reproductive health services are imperative.

More effort is needed to meet the SDG target of reducing the MMR to 70 per 100,000 live births. Mitigating disparities among provinces demands political commitment, active local leadership, community engagement, especially leveraging the youth force, and fostering public-private partnerships at all levels.

Surya Bhatta is Executive Director of One Heart Worldwide that works primarily on maternal health in rural Nepal.

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