aternal Health: Millennium Development Goals and Nepal

aternal Health: Millennium Development Goals and Nepal

Maternal Health: Millennium Development Goals and Nepal
Reduction in maternal mortality is one of the major goals of several recent international conferences and has been included in Millennium Development Goals (MDGs). Goal 5 of the MDGs targets at reducing the maternal mortality ratio by three-quarters, between 1990 and 2015.

The major indicators determined to evaluate the improvement in maternal health condition are: Decrease in maternal mortality ratio
Increase in the proportion of births attended by skilled health personnel.

More than half a million women die each year, and many suffers from life-long health and social problems as a consequence of complications during pregnancy and childbirth. The maternal mortality ratio (MMR) of Nepal is among the highest in the world. According to the Ministry of Health estimates, pregnancy-related complications kill over 4,500 women every year in Nepal with most of the deaths in rural areas where access to health services and health personnel are severely limited. The 1996 Nepal Family Health Survey revealed a MMR of 539 per 100,000 births. Human Development Report 2004 by the United Nations Development Program (UNDP) estimated the figure to be substantially higher at 740 per 100,000 births. However, the State of the World’s Children of 1998 published by UNICEF reported a MMR of 1,500 per 100,000 live births. It is thus very difficult to draw any conclusion regarding the trend of MMR in Nepal. But according to the UNICEF figures, it remains as one of the highest in south Asia.


Nepal’s initiative and status so far

Although the global initiative to reduce the maternal mortality and promoting safe motherhood practices started in mid-1980s, Nepal did not start safe motherhood national initiative till Cairo conference on population and development even though the country has one of the highest death rates. International pressure following the national health survey of 1996 forced the government of Nepal to take an initiation of a program of action. Nepal initiated Nepal’s Safe Motherhood Program in 1998. The program initiated with the objective to reduce maternal mortality focuses on increased access to family planning, essential obstetric care, essential neonatal care, comprehensive safe abortion services and skilled birth attendants.

Despite the governmental and non-governmental sectors initiative towards improvement of maternal health condition, Nepal still has not been able to attain significant reduction in maternal mortality.

According to the Nepal Demographic Health Survey 2001, one in two pregnant women receives antenatal care in Nepal, with 28% receiving care from doctor or nurse, midwife or auxiliary nurse midwife. In addition 11% receive care from a health assistant or auxiliary health worker, 3% receive care from a maternal and child health worker, and 6% receive care from village health worker. Most of the women who receive antenatal care get it at relatively late stage in their pregnancy and do not make the minimum recommended number of visits. Only one in ten women receives four antenatal care visits (considered as desirable no. of visits in the National Maternity Care Guidelines) during their entire pregnancy. Only one in ten (10%) women receives iron/folate supplements during pregnancy, and only 2% take them for more than three months.

In Nepal, approximately 80-90% of births take place at home, often attended by family members, sometimes by traditional birth attendant (TBA) and many without any attendant. Only 11% are attended by properly trained medical staff compared to the 2005 commitment of 80% birth attendants by skilled workers during a special session held by United Nations General Assembly in 1999 (known as ICPD +5). In absence of trained midwives, many women suffer from prolonged labor and complications caused by retained placenta. It has been estimated that 46% of maternal deaths is due to subsequent bleeding known as “postpartum hemorrhage”. In Nepal only 18.8% of women receive postpartum care. Maternal Mortality and Morbidity study (1998) conducted in three districts in Nepal (Kailali, Rupendehi, and Okhaldhunga) determined that the majority of women (67.4%), who died as a result of pregnancy, childbirth or postpartum period, were at home. Postpartum hemorrhage was determined as the leading cause of maternal death (46.3%), followed by obstructed labor (16.3%), eclampsia (14.3%) and puerperal sepsis (11.8%) in the same study.

Constraints

There is lot of implementation and operational constraints that has become a barrier towards the attainment of the goal. Programs regarding maternal health service have particularly focused on simply providing antenatal, child health and postnatal care rather than on quality care and extra care for women with obstetric complications. An issue regarding skilled birth attendants is also a major challenge.

Study done by Jahn et al. (2000) to assess the performance of maternal mortality care and its service components in Banke District in Nepal showed that the coverage of antenatal care was 28% of the district and skilled delivery care was 16%. Preventive activities in antenatal care were also partially implemented (only 17% receive effective iron supplementation). Little attention was provided in an individual counseling (average counseling was 1 minute per consultation). Furthermore, out of 41% of high risk pregnancies among antenatal attendees, only 15% received referral advices with follow-up in only 32%. Hospital deliveries accounted only 9.8% of total deliveries with wide urban-rural disparity (urban 36% vs. rural 4.5%).


What can be done?

An integrated approach that can improve antenatal, delivery and postpartum care together is very important to achieve effective and significant improvement in maternal health condition.

Various studies have shown better pregnancy and birth outcomes for the women who receive regular antenatal care starting first trimester of pregnancy. Periodic and regular visits with experienced health care providers such as midwife or physician can help women to monitor their pregnancy and seek advice. This can also help to detect and manage any signs of pregnancy complications. Routine maternal care and emergency treatment of complications during pregnancy, delivery and after birth; and postpartum and neonatal care, can prevent most of the maternal and infant deaths as well as improve maternal and child health.

Improvement in maternal health condition can be achieved only when skilled delivery services and quality obstetric care can be provided. To attain this, intervention should focus on skill development and quality training for the health workers and birth attendants, increase in quality antenatal and postpartum care, as well as continued supervision and evaluation. Interventions such as skilled attendance and institutional delivery should be targeted more on the poorest populations, where most of the delivery occurs at home including most maternal and neonatal mortality. Furthermore, in country like Nepal most of the deliveries if attended by birth attendants include traditional birth attendants. Thus capacity building and collaboration with these attendants can significantly improve maternal and neonatal mortality. In addition, community based interventions and awareness can further strengthen the improvement.

Nepal has still long way to achieve Millennium Development Goal of achieving 90% birth attendance by trained personnel and reduction in maternal mortality ratio to 200 per 100,000 births by 2015. Until and unless the above mentioned areas are improved, attainment of Millennium Development Goal is very difficult for Nepal.