Midwives to the rescue in Nepal

From 1991 to 2016, the maternal mortality rate in Nepal declined by a staggering 72% -- from 850 deaths per 100,000 live births to 239 in 25 years.

This was a dramatic advance, but since then progress has slowed and almost plateaued off, mainly due to high rates of neonatal deaths.

And at the current rate, Nepal will have to further bring down this figure by 71% by 2030 to meet its Sustainable Development Goals (SDGs) on maternal health. This is a considerable challenge given that Nepal has the highest maternal and neonatal mortality rates in South Asia, behind only Afghanistan.

A shortage of skilled birth attendants, weak referral systems and difficulty in accessing treatment for complex pregnancies all point to the government’s chronic neglect of women’s health and the subsequent high mother-baby death rate.

It is well established that the six pillars of safe motherhood are family planning, HIV/STD control, antenatal care, obstetric care, postnatal care and abortion care. And these can be strengthened through education, gender equality and access to primary health care. However, the Ministry of Health has overlooked these aspects, and this is undermining past gains.

The 2015 Right to Safe Motherhood and Reproductive Health Act guarantees women the right to necessary counseling and maternity services from a midwife. But this does not apply to a majority of women in rural areas due to a lack of trained staff.

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The government needs to produce more than 10,000 midwives with a minimum of a three-year certificate if it is to reduce the maternal mortality rate to 75 for every 100,000 births by 2030, as per the SDGs.

Under the previous Millennium Development Goal (MDG), Nepal had committed to reducing maternal mortality by three-quarters by 2015, which included midwifery education and services in the five-year plan. A policy was then formulated in 2006 to produce skilled birth assistants (SBA) with other staff to be given two months of training to develop 27 basic maternity services.

The strategy includes basic nursing skills in nursing and medical education such as ANMI certification, BSc Nursing, MBBS and MDGP and aims to produce professional midwives in the long run.

At present, Sudeni Maternal and Child Health Workers and Assistant Nurse-Midwife (ANMI) who underwent midwifery training for two months are deployed to communities as maternal health service providers.

Since 2006, the program has produced more than 10,000 SBAs and reduced maternal mortality by 15% in the past decade at the cost of Rs1 billion, but we are yet to see the kind of progress we aspired to. The program has significantly increased awareness about maternal healthcare, but has not produced as many professional midwives.

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In India, ANMI must have passed high school and undergone two years of training. In Nepal, those who have passed grade 8 and trained for 29 months can become ANMI. Therefore, people at the forefront of providing maternal and child healthcare are already lagging in resources, skills and education levels.

In urban centres, mothers have the choice of obstetricians and gynecologists, but in villages, their best bet are ANMIs, many of whom have not even completed remote obstetric training. This negligence has cost the lives of many young mothers.

Further, women accessing health facilities face humiliation, and even violence, and are stigmatised. The main reason for this is the lack of midwives, and the shortage of such an important position within the National Health Care System.

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There is also a tendency to announce popular programs only to source large budgets from state coffers. The President’s Program for Women’s Upliftment is an initiative to save the lives of mothers at childbirth.

Launched in 2018, the program has only spent Rs36.6 million in three years when its budget was Rs50 million a year. In the same period, while it saved 360 women, 789 died without treatment.

Expecting women in remote areas are constantly at risk due to the delays: at home while making a decision, on-road in lack of proper transport and at health facilities.

Even then we can mitigate the illiteracy, ignorance and financial constraints that cause decision delays at home and on roads with public awareness programs. But the bigger challenge is that of local health facilities take time to transfer women to better-equipped hospitals.

According to 2020 Maternal Infant Mortality Monitoring and Response (MPDSR), most maternal deaths were due to preventable causes such as bleeding, high blood pressure, infections and prolonged labour pains. The analysis also showed that 37% of women died on the way from one health facility to another, 30% at home, 23% in private and non-government hospitals and 10% on the way home from health facilities. Most of these deaths were of women under 34.

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By mobilising skilled midwives at local-level health facilities, we can manage many complications and counsel families if a mother needs to be relocated. And one way to achieve that is by providing the ANMIs with a 3-year certificate level midwifery education.

Midwives in essence stand for women's rights. They advocate for all women of reproductive age to receive the quality and dignified services they deserve, especially during pregnancy and childbirth.

Midwives have proven their effectiveness in countries like Norway, Finland, Sweden, Denmark and the Netherlands for the past 250 years and have reduced maternal mortality rates to as low as 2 per 100,000 live births.

With the maternity knowledge, skill and behaviour they have, only a midwife can determine the true condition of a woman in labour pain when there is no obstetrician and gynecologist present which is often the case across Nepal’s rural villages.

If we want to save our mothers, it is of utmost importance that the Nepali state act immediately to produce midwifery practitioners.

Laxmi Tamang is the president of the Nepal Midwifery Society.

Adapted from the Nepali original in Himalkhabar monthly magazine by Aria Parasai.

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