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HEALTH-NEPAL: On Course to Achieve MDG on Maternal Health

Mallika Aryal

KATHMANDU, Jan 12 2009 (IPS) - Impoverished Nepal has dramatically reduced maternal mortality cases from 540 per 100,000 live births in 2001 to the present 280 – a feat experts attribute chiefly to the legalisation of abortion.

"The number of deaths related to unsafe abortion was very high," says Indira Basnett, a leading reproductive health expert. "When abortion was legalised, the number of women dying due to pregnancy-related causes dramatically decreased."

Since 2002, abortion has been legal upon request during the first 12 weeks of pregnancy, when the woman's life or health is in danger, and in cases of rape, incest and foetal impairment. This decision came about in the form of an amendment to Nepal’s Civil Code.

From early 2004, the Nepali government began providing comprehensive care, training doctors and approving clinics all over the country where women could have abortion safely. Today, more than 177 approved government and private clinics in 71 districts provide abortion services to women.

But there were other interventions too. These include immunisation, reduction in fertility rate, iron supplementation, better skilled birth attendance, and substantial increase in the coverage of antenatal care, according to the United Nations Children’s Fund (UNICEF).

"Nepal is in line with meeting the [United Nations]Millennium Development Goals (MDGs) of reducing maternal mortality ratio (MMR)," John Brittain, an official at UNICEF, said. The MMR is the number of women who die at childbirth per 100,000 live births and Nepal must improve its figure to 213 in order to achieve that MDG.

From Wednesday onwards, Nepal’s ministry of health and population is introducing free delivery service in all district hospitals, primary healthcare centres, health posts and sub-health posts.

Nepal's MMR is already better than that of neighbouring India, Pakistan and Bangladesh. Sri Lanka has the best MMR in South Asia with a figure of 43 while, at the other end, Afghanistan has 1,600 deaths per 100,000 live births.

But there is no room for complacency in Nepal. According to a UNICEF statement key areas that need attention include birth spacing to avoid unwanted pregnancies, and provision of emergency obstetric care services, modern equipment and trained personnel.

"Reduction of pre- and post-delivery hemorrhage and infection is the key to saving the lives of pregnant women," says Shyam Raj Upreti, chief of the expanded programme on immunisation in the child health division.

Upreti says it is crucial to have more doctors and health workers who are trained in delivery.

"Immunisation against tetanus is provided through the Nepal health service to all pregnant women who seek antenatal care, and it is a big contributor towards bringing down maternal tetanus," says Aruna Upreti, a public health expert.

More expectant mothers are aware today about personal hygiene and more women are getting married later, she said. The government has made provisions for pregnant women who make at least one prenatal visit to a doctor to be also given iron supplements to cut anaemia, once a major contributor to fatal hemorrhaging after delivery.

Today, just a third of Nepali women are anaemic, down from 75 percent five years ago. Vitamin A supplements, given after birth to boost immunity, have reduced infections in new mothers.

Through education campaigns and expanded clinic networks Nepal also has managed to boost births at hospitals from 10 percent to 20 percent of the total 800,000 reported annual pregnancies, and increase the number of postnatal visits to clinics by more than 30 percent.

Basnett says more women also aware of family planning today. The government's network of village health workers has raised awareness of maternal health and care of pregnant women, and the growth of privately run health services specialising in obstetric care has also helped to reduce the mortality rate.

The government only provides emergency obstetric care in the zonal hospitals. Patients either have to walk for days to reach them, or must drive or fly to Kathmandu. It is often cheaper for family members to take the pregnant woman to a private clinic in the nearest urban centre.

Nepali public health experts warn that the current rate of death is still higher than it should be and that the apparent improvement in mortality rates may be misleading. They say that in Dadeldhura, Bajura, Bajhang, Mugu and other districts in far-west Nepal, there is unlikely to have been much improvement.

"We are talking about areas where there are no doctors, women deliver at home, and if they die their deaths are not registered, areas where women suffer from acute malnutrition, haemorrhaging, and infections. Pregnancy-related deaths rates are still very high there," warns Aruna.

Upreti of child health division agrees: "When the maternal mortality rate was 540 per 100,000 live births, we had estimated more than 1,000 deaths per 100,000 live births in rural Nepal. That cannot have changed much."

Asok Sharma, a public health expert now working with Merlin Sri Lanka in strengthening local-level maternal and child health, says that the 12 years of ‘people’s war’ devastated the country's health systems.

"In conflict areas, routine services were not provided, health workers were confined to headquarters, not a single doctor was available, and services were not upgraded. How could maternal mortality have gone down in these areas?" Sharma asks.

Experts say the key to future improvements lies in building the capacity of health workers and midwives deployed at the village level. There is also a need to register pregnancies and to provide specialised obstetric and neonatal care beyond just the zonal hospitals.

Nevertheless, reducing MMR by nearly 50 percent is no small feat and Basnett is confident of further reduction.

"If the service is accessible, acceptable in terms of quality and affordable, then we can save more women. Let this be the lesson to doctors, health workers, midwives, public health experts and government while devising future policies relating to maternal health,'' she says.