Reducing Maternal Mortality in Nepal

Dr Naresh Pratap K.C. Ministry of Health and Population, Nepal

Photo credit: Stephjanie Suhowatsky

Photo credit: Daniel Antonaccio

Health and Development in Nepal

Population: 30 million, diverse ethnic groups Post-conflict, transitional democracy Diverse topography Large-scale out-migration With 80% of the Nepals population living in rural areas amid challenging topography Equity, access and social inclusion key political and development issues

Photo credit: Save the Children, Nepal

Improving Maternal & Child Health in Nepal Dramatic declines in

TFR dropped to 2.6 MMR from 539 to 281 (DHS 1996,2006)
180 160 140 120 100 80 60 40 20 0
Under five mortality rate

child mortality Improvements in maternal health

153 102 46

Infant mortality rate Neonatal mortality rate

118
79 50

Most women in Nepal 33 still deliver at home 1991 1996 2001 2006 2011 (64%) and without a skilled provider (65%) NMR remains unchanged: Estimated 32,000 newborn deaths/year during their first monthmost in first week

91 64 39

61 48

54 46 33

54 34 15
2015

Source: NDHS

Maternal Health in Nepal

Maternal causes leading cause (21%, 1998) of all deaths of women of reproductive age; suicide now leading cause (16%, 2009) Causes of maternal deaths have shifted:
PPH dropped from 46% to 17% Eclampsia now leading cause (21%)
Infection, 12% Antepartum Hemorrhage , 5%

2009
Other indirect, 16%

Antepartum Hemorrhage, 7% Postpartum Hemorrhage, 17%

Other direct , 6% Puerperal Sepsis, 5% Gastroenteriti s, 4% Anemia, 4% Eclampsia, 21%

Obstructed Labor, 18%

Postpartum Hemorrhage , 46%

Abortion, 5%

Obstructed Labor, 6%

Heart Disease, 7%
Eclampsia, 14%

Abortion, 7%

1998

4
Source: Maternal Mortality and Morbidity Survey, 1998, 2009

Health System in Nepal

75 districts

Each divided into

Village Development Committees (VDCs) Each VDC has a health facility

Health services in cities/towns are managed by municipalities 8 health worker cadres Almost 50,000 female community health volunteers mobilized

Source: Department of Health Services Annual Report 2066/2067 (2009/2010)

Community Health System

Each VDC has nine wards & 1 health facility
3
6 4 2 1

Settlement

FCHV
Settlement

7
5

Mothers group
8

Settlement

District is divided into VDCs

Each ward has: 80-100 households 1 Female Community Health Volunteer

75 districts in Nepal

(FCHV) who provides maternal and child care services in the community. A mother group coordinated by FCHV for community mobilization

Interventions to Reduce Maternal Mortality

Continued successful family planning services program Developed Birth Preparedness Package (2001) Legalized abortion (2002) Addressed anemia: iron intensification, deworming (2003-2004) Developed SBA Policy (2005) Distributed Misoprostol for home births (2006) Launched SBA inservice training initiative (2006-7) Introduced AAMA Programme:
Safe delivery incentive (2005) Free maternity care (2009) Introduced ANC and PNC incentive (2010)
1996 2006

Expanded CEOC and birthing centers (2007-2008) Piloted community-based newborn care package (2008) Expanded adolescent-friendly RH services in 35 districts (2008-2011)

Measurements of Maternal Mortality

1600 1400 1200 1000 800 600 400 471 539 865 830 740 830 1500

343

281

240 229

200
0 1980 1985 1990 1995 1996 2000 2005 2006 2009

DHS

Hogan Model

UN Model

FHD/SSMP

Source: Oona Campbell presentation, 2010

Methodology
STUDY DHS Maternal Mortality and Morbidity Study Frequency 10 years 10 years Method Sisterhood Coverage National

Prospective 8 districts community verbal autopsies

Photo credit: Geeta Sharma

Improving Equity and Access: Study in 6 Districts

Source: Early Evaluation of the Aama Programme presentation, 2010

Contributors to MMR Reduction

Reductions in fertility (reduced lifetime risk of maternal death) Reduced anemia rates Development improvements: education, wealth, HDI Gender empowerment Increased met need for EmOC Safe abortion services
Source: Investigating Recent Improvements in Maternal Health in Nepal: Further Analysis of the 2006 Nepal Demographic and Health Survey, 2008; Hussein et al. An Appraisal of the Maternal Mortality Decline in Nepal, 2011

MoHP Results
Total Fertility Rate (TFR)
5 4.5 4 3.5 3 2.5 2 1.5 1 0.5 0 4.6 4.1 3.1 2.6

1996

2001

2006

2011

Implications for the National Maternal Health Strategy

Eclampsia top direct cause of maternal mortality 41% of maternal deaths occurring in facilities 2 of 3 births still occurring at home No reduction in NMR Declining TFR, stagnating CPR High unmet needs among under-served, excluded groups and the poor

Remaining Challenges
Reaching remote areas, underserved populations, excluded groups Human resource shortages, especially in remote areas Motivating and sustaining a large volunteer network Health sector reform

Photo credit: Geeta Sharma

Thank You

Photo credit: Stephjanie Suhowatsky