Focus on Maternal and Child Health

Striving to improve the health of women and children

The Scale of the Problem

As in many resource-poor settings, Nepal has one of the highest maternal and neonatal deaths in the world. According to the recent Nepal Demographic Health Survey 2006, 281 women per 100,000 live births die of complications during childbirth and 33 newborn die per 1,000 live births; two-thirds of the total neonatal death is in the first week of life (MoHP Nepal, New ERA, and Macro International Inc. 2007). This means that a newborn baby dies every 20 minutes and every 4 hours a woman dies of childbirth related causes. In comparison, maternal mortality ratio is 90 in Sri Lanka and just 8 per 100,000 in the U.S. – thus it still ranks among the highest in the world. Most of these deaths occur in rural areas. High maternal and neonatal death rates are the indicators of an inadequate health care system, with poor quality of care and limited access to services. Around 40 percent of the neonatal deaths are due to preventable causes like infection and birth asphyxia.

Similarly, around 69 percent of maternal deaths are due to avoidable causes such as haemorrhage, eclampsia, abortion, obstructed labour, puerperal sepsis and anaemia respectively (Suvedi et al 2009). Many of those deaths are direct consequences of under utilization of maternal health services and low quality of care, especially in remote areas that could have been easily prevented by a health worker with the right skills, the right equipment and the right support.

Although many factors contribute to maternal mortality, health experts from around the world have identified three main factors for this terrible mortality rate, referring to them as ‘the three D’s.’ They list them as “the delay in taking the decision to seek medical assistance”, “the delay in accessing the appropriate care” and ‘the delay of care at health centers”. They identified that the lack of access to a trained midwife as being at the top of the list. Moreover, a lack of access to medical care, poor health education and the low status of women are the main causes in the context of Nepal. Only when a large proportion of women are cared for by skilled attendants can this mortality rate drop significantly. Evidence has show that up to 90 percent of maternal deaths can be prevented when midwives and others with midwifery skills, i.e. skilled birth attendants (SBAs) are authorized and supported by the health system to practice their full set of competencies (World Bank 2003; WHO 2005; UNFPA 2006). In Nepal, the most critical issue with the newborn, including women’s health, is that more than 80 percent of deliveries occur at home in the absence of SBAs. The vast majority of births are assisted by relatives or family members or women on their own. In addition, the uptake of maternal health services is very poor. Only 29 percent of Nepalese women make the recommended four antenatal visits, 19 percent of the childbirths are attended by SBAs, and only 18 percent women give birth in a health facility (NDHS 2006).

However, the Nepalese government is striving to achieve the millennium development goals 4, reducing child mortality and 5, reducing maternal mortality and are targeted to achieve of 15 per 1000 and 134 per 100,000 by 2015 respectively from the current level (GoN 2009). In order to attain these goals, it requires 60% of births to be attended by SBAs and 40% of childbirth at a health facility by 2015, for which around 5,000 SBAs are required by 2012 (GoN 2006a). This is the enormous challenge to the nation, since at present, maternity care is primarily provides by health workers, who are not competent in midwifery skills. In Nepal, the only midwifery care providers in the community settings are Maternal and Child Health Workers with three-month pre-service midwifery training after eight years schooling and Auxiliary Nurse-Midwives (ANM) with 18-months of pre-service education after 10th grade. ANMs are trained to assist women in normal deliveries and identify complications during pregnancy. Because these workforces have a limited educational background and limited midwifery training, they are not competent and confident even in providing normal childbirth care to women during labour. But ANMs are also required to assist women having prolonged labours and complications such as incomplete abortion, retained placenta and to administer life-saving drugs during emergencies because they have been deployed to places inaccessible to proper healthcare facilities, where nurses and doctors are not available.

However, since they are working in rural, community-level health facilities nationwide, they are contributing more to saving women’s and newborn’s lives in Nepal.

Sadly, midwifery is neither an independent profession in Nepal, nor exists a separate cadre of midwife. Because of this, there is no legislation and no recognition of professional midwives. Nurses involved in providing maternity care are usually called nurse-midwives. Evidence across the globe shows that without having professionally competent professionals with midwifery skills, who provide a scientifically-sound, hygienic and humanistic social model of maternity care, it is challenging to confront the situation in saving lives of mothers and newborns (WHO 2005). Midwives deliver – and not only babies. They save lives and promote good health in societies as a whole. They are an essential workforce in an effective healthcare system.

In Nepal, it does not seem that the maternal mortality is just a public health indicator but it is more a human rights and gender discrimination issue.

Home Births

In Nepal, 81 per cent of births take place at home with the assistance of relatives, friends and untrained traditional birth attendants, according to the Nepal Demographic Health Survey 2006. Only 19 per cent are attended by skilled birth attendants. In the absence of professional midwives in Nepal, many women suffer from prolonged labour and complications caused by a retained placenta. According to statistics, a large number of them die from subsequent bleeding or ‘post-partum haemorrhage’ amounting to
about 46 percent of maternal deaths.

Reasons for Delays

The problems arise when family members in rural areas don’t take immediate action to get the woman to hospital, according to some
health experts. The low value of the daughter-in-law in Nepalese culture and cash problems lead to the delay.

According to one recent report from the eastern Morang district, a woman in her fifth pregnancy and under medical supervision, suffered from internal bleeding after her uterus ruptured. Family members refused to donate blood when asked by the doctor.
“If she dies then that is her fate,” the family members, including her husband, told the doctor. “I will feel weak if I give her my blood,” said the husband. In less than an hour, she was dead.

“This is an example of how low women are valued and how they are so grossly discriminated [against],” health worker Upreti explained. She has travelled extensively in the most remote areas to treat pregnant women. “She did not die due to a lack of doctors or medicines,” said Upreti.

Efforts to Reduce the Problem

Although the global initiative to reduce maternal mortality and promote safe motherhood practices started in the mid 1980s, Nepal was slow to start any national initiative despite having one of the highest death rates. It was only after the Cairo conference on population and development that Nepal finally launched the national safe motherhood plan of action.

International pressure, following the national health survey of 1996, pushed the government of Nepal into initiating a programme of action.

Nepal has a long way to go to achieve the Millennium Development Goal of achieving a 60 per cent attendance at birth by skilled birth
attendants (doctors, nurses, midwives) and reducing the maternity mortality ratio to 134 per 100,000 births by 2015. By recognizing these challenges, since 2006 the government of Nepal has introduced measures to improve safety for mothers such as free childbirth services if they deliver at a public health institution and they also receive their travel costs but little seems to be working. Still the majority of women are not accessing maternity services. The National Safe Motherhood and Newborn Health Plan for fifteen years was developed in 2006, to accelerate the actions in achieving the goals. This followed by the development of the National Policy on SBAs in the same year, and the National SBA Training Strategy.

During these years, Nepal moved away from training Traditional Birth Attendants (TBA) to training SBAs, to reduce maternal and newborn deaths. Despite the rigourous effort from the government and international development partners in improving maternal health status in the country, according to the Department of Health Services latest figure of 2010, the proportion of births attended by SBAs has increased to 29 percent. There is still a long way to go to achieve the national goal of 60% of births delivered by SBAs, by 2015.

To fulfill these commitments, the Ministry of Health and Population developed the National Policy on Skilled Birth Attendants (SBA) in June, 2006 within the National Safe Motherhood Policy 1998 that placed emphasis on:

  • Strengthening maternity care, including family planning services at all levels of health service delivery including the community. The National Safe Motherhood Plan 2002-2017 developed a long-term vision to scale up the coverage of maternal and newborn health care at all levels of health care delivery system.
  • Strengthening the technical capacity of maternal health care providers at all levels of the health care system through training. The National Safe Motherhood Training Strategy-2002 focused on strengthening pre-service and in-service training institutions to ensure that all health providers have appropriate skills according to the national Reproductive Health Clinical Standard 1998.
  • Deploying and providing appropriate support and personnel for each level of maternity services was an identified objective. The importance of appropriate human resource as an essential component of ensuring quality maternal health services was reiterated in the Nepal Strategic Plan for Human Resources for Health 2003-2017.

This SBA Policy addresses the gaps identified by the National Health Policy-1991 and Nepal Health Sector Programme-Implementation Plan (NHSP-IP) 2004-2009. The SBA Policy is linked to other national policies and strategies. This SBA Policy is concurrence with the NSHP-IP 2004- 2009 with output one and output seven.

According to the National Policy of SBAs 2006, SBAs are persons with midwifery skills – doctors, nurses or ANM, with additional training to complement their skills gained during pre-service training. SBA training results in upgrading their skills to manage normal uncomplicated pregnancies and in the identification, management and referral of complications, in women and newborns, with doctors having advanced SBA skills including Caesarean section (GoN 2006b). The major focus to date in Nepal has been on the short term strategy of developing SBAs through providing short in-service training for already qualified doctors, nurses and ANMs to enhance their midwifery skills.

The National Policy recognizes the need to focus on medium term strategies besides in-service training, by strengthening pre-service training of ANMs, nurses and specialist doctors to include skilled birth attendance. Some progress has been achieved in this direction; SBA competencies have been incorporated in the pre-service curriculums of nurses and specialist general practitioners by the academic institutions/ universities. So far, 2,268 SBAs have been produced in the country by providing training to the existing doctors, nurses and ANMs.

The Policy also defines the long term strategy to sustain SBAs and to achieve 60 percent deliveries attended by SBAs, through initiating the development of a cadre of professional midwives as a crucial human resource for safe motherhood, for providing service and leadership in midwifery for the country. However, as envisioned in the long-term (preservice) measures to produce a new cadre of professional midwife through a direct-entry professional midwifery programme as a crucial human resource for safe motherhood, this measure has not been taking seriously by the policy-makers, program managers and planners of the Ministry of Health and Population. In order to be able to reach the target of 60 percent deliveries by a SBA in 2015, Nepal needs an additional 5,000 SBAs to be recruited in the national health care delivery system by 2012 (GoN 2006a). However, according to the National in-Service Training Strategy for Skilled Birth Attendants (SBAs) 2006 – 2012, only in 16 mountain districts over 2208 SBAs must be trained and recruited by 2012 if 60% births to be attended by SBAs by 2015.

Additionally, training is not the only issue; regulation, accreditation, and supportive supervision of SBAs are equally important to ensure that these cadres have appropriate protection, remuneration, incentives and motivation. Therefore, to advocate for this and to strengthen the skills of existing ANMs and nurses involved in providing maternity care, both in the private and public sectors APS took major role for the establishment of the Midwifery Society of Nepal in February 2010.