Increase skilled human resources to prevent non-institutional child deliveries

When Pansara Rokaya (31) of Kuru village in Budhinanda Municipality-4, Bajura, delivered a baby girl on the way to a local health post recently, it became national headlines. 

Similarly, Bhagya Chadara ( 21) from Majhpali village in Gaumul Rural Municipality-3, Bajura, gave birth on the way to the hospital in the neighboring district of Achham. She had been referred to Bayalpata Hospital in Achham as the Bajura District Hospital didn’t have a doctor to provide emergency parturition service.

Earlier, Nani Rokaya of Bamu of Himali Rural Municipality-1, Bajura, had also given birth on the way to Bamu Basic Health Service Centre, just three hours away from her home. 

The stories of these women echo the predicament faced by many women living in remote corners of Nepal. Despite the promises laid out by the Right to Safe Motherhood and Reproductive Health Act, 2018, the ground reality paints a different picture. Women find themselves compelled to bring life into the world without the presence of healthcare professionals. 

The Nepal Demographic Health Survey (NDHS) 2022 reveals that while 94 percent of women receive antenatal care, the disparities in education and wealth play a pivotal role in determining access to essential services.

For most women living in remote parts of Nepal, the journey of childbirth becomes a perilous venture as the statistics on place of birth demonstrate a concerning trend. The NDHS survey reveals that women with no education (67 percent) and those in the lowest wealth quintile (75 percent) are less likely to have at least four antenatal care visits than those with more than a secondary education and those in the highest wealth quintile (93 percent each). Deliveries at a health facility are least common among Muslim women (67 percent) and most common among Brahmin/Chhetri women (87 percent) as per the health report. 

For survival and well-being 

Health care services during pregnancy and childbirth and after delivery are important for the survival and well-being of both the mother and the newborn. Antenatal care (ANC) can reduce health risks for mothers and newborns through monitoring of pregnancies and screening for complications. 

“Delivery at a health facility, with a skilled human resource reduces the risk of complications and infections during labor and delivery. It helps prevent postpartum hemorrhage,” says Dr Manor Din Shaiyed, senior obstetrics and gynecologist at Manmohan Memorial Medical College and Teaching Hospital, Swoyambhu. 

Timely postnatal care offers an opportunity to treat complications arising from delivery, provide intensive care for the newborn, and teach the mothers how to care for themselves and their newborns. 

Trends in place of birth

Year Delivered at home Delivered in health facility

1996 91 8

2001 88 10

2006 78 20

2011 54 44

2016 35 64

2022 19 79

Percent of live births in the two years before the survey

(Source: Nepal Demographic Health Survey 2022)

The proportion of health facility deliveries is lowest in Madhesh Province (67 percent), followed by Karnali Province (72 percent). The proportion is highest in Bagmati Province and Gandaki Province (88 percent each), followed by Sudurpashchim Province (87 percent).  Institutional delivery helps in preventing neonatal and child mortality. Neonatal mortality as a percentage of under-5 mortality has increased sharply in the country. With the lack of the health facilities in the country the share of neonatal deaths has increased from 64 percent of infant deaths in 1996 to 75 percent in 2022, as per the NDHS report. 

The neonatal mortality rate, infant mortality rate, and under-five mortality rate are 21, 28, and 33 deaths per 1,000 live births, respectively. Childhood mortality is highest in Sudurpashchim Province (neonatal, infant, and under-five mortality rates of 27, 40, and 49 deaths per 1,000 live births, respectively).

Lack of institutional services gives rise to maternal deaths.The World Health Organization reveals that almost 95 percent of all maternal deaths occurred in low and lower middle-income countries in 2020 and most could have been prevented. Care by skilled health professionals before, during and after childbirth can save the lives of women and newborns.

Maternal mortality

Women die as a result of complications during and following pregnancy and childbirth. Most of these complications develop during pregnancy and most are preventable or treatable. The major complications that account for nearly 75 percent of all maternal deaths are—severe bleeding (mostly bleeding after childbirth), infections (usually after childbirth), high blood pressure during pregnancy (pre-eclampsia and eclampsia), and complications from delivery. With a maternal mortality rate of 239, one out of every 167 women aged between 15 and 49 years in Nepal, could die unnecessarily from complications in pregnancy or childbirth, states Family Welfare Division.

 The leading causes of reported maternal deaths from 28 hospitals during a four-year period (2015–18) were eclampsia (19 percent) and postpartum hemorrhage (17 percent). Most maternal deaths occur within 48 hours of delivery (42.7 percent) and then in the late postpartum period (from 48 hours after birth to up to six weeks after childbirth).  Severe bleeding after birth can kill a healthy woman within hours if she is unattended. Injecting oxytocics immediately after childbirth effectively reduces the risk of bleeding. That’s why every pregnancy should be delivered in the health facilities, added Dr Shaiyed. 

The Ministry of Health and Population in collaboration with the National Statistics Office had collected data on live births and deaths of women of reproductive age (WRA) in the enumerated households for the last 12 months preceding the National Population and Housing Census 2021. Of the 653 pregnancy-related deaths, 611 maternal deaths were analyzed further for causes and attributes the study showed that many maternal deaths in Nepal are due to preventable causes such as hemorrhage and high blood pressure during pregnancy.  

According to the report published by the Nepal government, around 17 percent of women had died either while traveling from their residences to the health facilities or between the facilities. 

How can women’s lives be saved?

Nepal has committed to reducing its maternal mortality rate from 281 per 100,000 live births in 2006 to 116 by 2022, 99 by 2025, and 70 by 2030.  The country has already missed its 2020 target to reduce maternal mortality to 125 per 100,000 births. 

“If the government really wants to achieve the goal then it’s vital to make easy availability of delivery services in health facilities,” says Dr Shaiyed.

As per the Family Welfare Division under the Department of Health Services 1,100 women die because of complications related to pregnancy each year.  Access to high quality care in pregnancy, and during and after childbirth is important. It is important that all births are attended by skilled health professionals, as timely management and treatment can make the difference between life and death for the women as well as for the newborn, he adds.

Programs for safe motherhood

The government has its Aama and the Newborn Program where transport incentive is given to women immediately following institutional delivery: Rs 1,500 in mountains, Rs 1,000 in hills and Rs 500 in Tarai districts to encourage women to deliver in health institutions. Likewise, the President Women Upliftment Programme (PWUP) was launched on 8 March 2017 as a flagship program to meaningfully transform the life of disadvantaged, poor and marginalized women.  Women with long labor pain, those whose babies have died inside the womb, excessive body swelling during pregnancy, excessive bleeding after delivery, anemic pregnancy and those who have not been able to get treated in the local health centers are rescued by air under this program. 

 

The government provided free air service to 304 pregnant and postpartum women till January 2022.  In the fiscal year, 2075/76, 26 pregnant women were airlifted, 87 in the fiscal year 2076/77 and 103 pregnant women were airlifted in the fiscal year 2077/78.  Though the government has been trying to increase the hospital based deliveries it must increase the human resources, provide proper counseling to pregnant women, establish birthing centers, increase skill birth attendants if it really wants to increase the institutional based delivery and decline maternal mortality rate and neonatal deaths in the country.