Cover Story (Spotlight Weekly)

MATERNAL MORTALITY

Killing Mother

Despite some improvements in the health infrastructure of this country, a large number of women still do not receive minimum health facilities during pregnancy. At a time when the country’s basic health facilities are severely disrupted by the growing violence in the rural hinterland, a large number of women are denied basic treatment. The limited achievements of the last five decades do not prevent Nepal from turning into a country with the highest mortality rate in the world. Among observers from the prime minister to donors, there is growing realization of the need to improve the present situation. The question remains of how to make women’s lives safe.

By KESHAB POUDEL

Jamuna Rai,17, a resident of Bhojpur district, 400 miles of east of capital Kathmandu, died a few hours after delivering a baby boy. Rai was declared dead from over bleeding at the local health post. Had Rai been attended by trained medical staff, she would have survived.

Jamuna is not the only mother to die because of simple medical complications occurring in the post natal period. Every two hours, a Nepalese woman, usually young, dies while giving birth to a child. Maternal mortality in this landlocked Himalayan Kingdom is one of the highest in the world.

“Though Nepal has strengthened and expanded family planning services, the inequality in services between urban and rural areas is glaring. It is painful to note that even today over 90 percent of deliveries take place at home, trained health workers assist only 13 percent of deliveries and more than 67 percent of maternal deaths occur at home. Poverty, illiteracy, ignorance and to some extent cultural practices have added difficulties to the problem. In recent years, the terror and trauma created by the violent and destructive acts of the Maoists have further aggravated this situation,” said prime minister Surya Bahadur Thapa.

Women : Variety of problems

Donor communities have also shown concern about the growing maternal mortality rate. “During the two hours we are devoting to this event, somewhere in Nepal a woman will die in childbirth or as a result of pregnancy,” the UN Resident Co-coordinator in Nepal said, while addressing a UN Day gathering recently.

According to government reports, Nepal’s maternal mortality rate is 539 in 100,000 births. After Afghanistan, which has a maternal mortality rate of 1276 in 100,000, Nepal has the second highest maternal mortality rate in South Asia and it is regarded as one of the highest in the world.

With support from UN agencies such as UNFPA and WHO and bilateral donor agencies such as USAID, many programs have been launched to improve the situation. However, people living in the rural parts of the country have yet to receive proper antenatal and delivery care.

According to Nepal Demographic and Health Survey 2002, assistance at delivery from a doctor or nurse/ANM (Assistant Nurse Midwife) is relatively low in Nepal. Just one in ten births is attended by a doctor or nurse. Nearly, one in four births is attended by relatives or friends. Nine percent of births are not attended by anyone at all. Births to young mothers, the first-order birth (birth of a first child) and births in the hills or Terai region are more likely to be attended by a doctor or nurse/ANM.

The report also shows that an educated mother is more likely to seek the advice of a medical practitioner at the time of child delivery. Nearly one in two births to mothers who have a School Leaving Certificate or higher education is attended by a doctor compared to one in four births to mothers with some secondary education, one in ten births to mothers with primary education and less than 4 percent of births to mothers with no education.

Few weeks ago in a program entitled Maternal and Neonatal Health (MNH) dissemination program, policymakers, health workers and donor representatives revealed the serious consequences of high maternal mortality in rural society.

New Initiative

Jointly implemented by the John Hopkins Center for Communication Program, the Center for Development and Population Activities and the Program for Appropriate Technology in Health, MNH Program is committed to saving the lives of mothers and newborns by increasing the timely use of key maternal and neonatal health and nutrition practices.

Under the MNH, a national Safe Motherhood Communication Initiative –A National Safe Motherhood Communication Initiative – SUMATA – has been implemented in Nepal to promote birth preparedness as well as the ability to handle complications and emergencies.

SUMATA is thematic abbreviation for care, share and prepare. Jeevan Suraksha (Birth Preparedness Package or BPP) was developed as part of a social mobilization strategy to promote behavioural changes.

“There is a need for coordination, communication, and technical collaboration among safe motherhood partners,” said Dr. Yasobardhan. Pradhan, director of the Family Health Division. “We have already initiated competency based training and training sites have already been developed in Koshi and Patan.”

Since most rural women still follow traditional practices, there are high possibilities of post natal and pre-natal complications. “Our program has changed the behaviour of pregnant women in general and other women in particular,” said Dr. Piush Mishra of MNH-Nepal and Shailesh Neupane – VARG presenting Quantitative Results of the Sumata.

Being fundamentally a comprehensive and participatory approach, BPP is considered the main arm of the IPC activities in SUMATA. Primarily, Jeevan Suraksha is aimed at encouraging pregnant women, their families and the community at large to plan for normal pregnancies, safe deliveries and to be prepared for emergencies.

Manju Karki, 19, a resident of Tityan VDC of Baglung district, 250 miles west of capital Kathmandu has studied up to class IX. Understanding the importance of saving life, Manju stresses the need to go to a health facility such as a hospital, health post or a private clinic in case complications arise either during pregnancy or at the time of delivery. During interviews by SUMATA and Jeevan Suraksha of recently delivered and currently pregnant women in Baglung and Lalitpur, Karki shared her own experiences.

Resha Malla, 22, a currently pregnant woman from Sano Gaun, a village in Lalitpur, 8 miles south-east of Kathmandu has different story to tell. After being exposed to SUMATA, Malla realized she needed to go to a health post or hospital in case of complications during her pregnancy.

In most of the rural areas, pregnant women are often forced to carry heavy loads and have to work hard in the field. They do not find hospitals and other medical facilities in the vicinity. They have to rely on traditional birth attendances or family members to know the pregnancy.

As there is a need to increase awareness levels, SUMATA focuses its attention on generating awareness among the rural population about pregnancy and maternal health. From street theatre to television serials and radio spots, SUMATA has been taking various initiatives to disseminate information.

“There is a need to improve knowledge regarding the complexity of pregnancy and post-natal and pre-natal medical requirement among pregnant women,” said Sheila Lutjens from the USAID. The US government has long been supporting Nepal to improve the situation.

Studies have shown that the lives of many women can be saved by offering them basic information regarding cure and protection during the pregnancy. “Our program succeeds in enhancing knowledge about the care in post-natal and pre-natal period among pregnant women in different parts of the country,” said Ms. Diane Summers.

No Health Facility

Maternity hospital : Need to extend services to rural parts

One of the main reasons behind the high maternal mortality rate in Nepal is the lack of health facilities and lack of manpower to provide primary care. Even in normal political conditions only a small percentage of the population had access to health facilities. Assistance at delivery from a doctor, nurse or Assistant Nurse Midwife (ANM) is relatively low in Nepal. Approximately 10 per cent of women receive assistance from a doctor, nurse or ANM during delivery and 90 per cent of women give birth to their children at home surrounded by traditional birth attendance or family members. The maternal mortality and morbidity study shows that majority of maternal deaths are due to postnatal complications.

Over the last eight years, the insurgency has destroyed Nepal’s limited health infrastructure and networks. The remaining health infrastructures are non-functional in the absence of medical staff. Many pregnant women in rural parts of the country do not get basic medical care during their pregnancy.

“With the upsurge of violence, many health infrastructures including rural health posts and health units have been destroyed resulting in scarcity of medical facilities for the pregnant women,” said Roshan Karki, president of Aama Milan Kendra, a non-governmental with a nationwide network and which works in the field of safe motherhood and adolescent health. “Because of growing threats [from Maoists], non-government organizations like ours have also had to close our offices.”

In many remote areas, none of the pregnant women have ever been in contact with a health worker. Poor maternal nutrition and health, short birth intervals, and the inaccessibility to emergency obstetrical services contribute to Nepal’s high levels of maternal and neonatal mortality and morbidity.

The situation is worsening thanks to the widely practiced tradition of early marriage and most importantly the fact that most of the married girls are illiterate. “In Nepal 23.6 percent of the population is aged between 15-19 and the 10-24 age group represents one-third of Nepal’s population. Almost 30 percent of children are not attending schools. Among those who attend, girls become the first to drop out. Almost half of girls aged 15-19 are already married and 21 percent of them are already pregnant or have their first child by this age,” said Dr. Hernando Agudelo, acting representative of UNFPA/Nepal.

Since the girls are not properly fed and cared for, there is a high possibility of fatality for girls during pregnancy. “The young rural girls, who are usually unprepared for pregnancy and motherhood, and are under-nourished and under-fed, face a higher chance of death or morbidity as a result of their pregnancy,” said Karki, president of Aama Millan Kendra, a non-governmental organization working to promote safe motherhood. According to the Department of Health Services, one fifth of maternal deaths occur among adolescent girls.

There are many factors contributing to the increase in the maternal mortality rate. “Our studies have shown that unsafe delivery, postnatal complications, early marriage and unsafe abortion is responsible for higher maternal mortality rate,” said Tek Bahadur Dangi, public health expert at Family Health Division of Ministry of Health. Annual Report of Department of Health Services 2000/01 showed that 11 per cent of pregnant women were teenage or below the age of 20.

The health services are inadequate and there is a little hope for the rural population to secure the treatment at health posts during the emergency period. “Only a small percentage of even the urban population has access to an Antenatal Clinic (ANC), Postnatal Clinic (PNC) and delivery with doctors,” said Dr. Ramhari Aryal, a demographer with National Planning Commission, an apex policy making body. “We will introduce more effective programs to reach pregnant women. Since the amendment of Civil Code Act, women can now go for legal abortion.”

Risk of Abortion

Despite the legitimization of abortion, abortion complication is a major problem in Nepal and 20-27 percent of maternal deaths in the hospital are due to complications resulting from abortions. A maternal mortality and morbidity study in 1998 showed that 5 per cent of the deaths are due to abortions in the villages. Although the Ministry of Health extended Post Abortion Care Program in 19 hospitals, it has yet to prevent deaths from abortion. Most of the women in abortion cases die before reaching hospital.

The records collected by the National Maternity Hospital in Kathmandu in 2002 showed that nearly 10 per cent of the 18,000 patients admitted at the hospital were related to abortion cases. Last month a woman died in Koteswor, a town near Kathmandu because of complication in abortion. She died a few days after the abortion of her four-month-old foetus.

Low Level of Literacy

Although literacy has increased tremendously, large numbers of girls are denied their right to go to school. There is a need to invest in girls’ education. According to UNFPA’s State of the World Population Report 2003, 76 per cent of females above 15 years are illiterate, against 43 male. According to the report, the births per women aged 15-19 is 117 per 1000. “Maternal morbidity and mortality are closely related to literacy. Educating adolescents will dramatically change the status,” said Karki. According to a UNFPA report, some 82 million girls around the world between ages of ten and seventeen will marry before their 18th birthday. Some 14 million teenagers, married and unmarried, give birth each year, and many face serious pregnancy-related illness. Five million undergo unsafe abortions.

Manmaya Magar, 17, of Rukum district 300 miles west of the capital, died recently as a result of delivery complications. According to a newspaper report, she was declared dead due to over bleeding as soon as she reached the local health post in the district capital. Magar was reported to be illiterate.

Like Magar, many girls are married off without knowledge of the functions of organs of their bodies and most of the young girls get pregnant unaware of reproductive health. Studies have revealed that large numbers of mothers who die in pregnancy complications are illiterate.

Early Marriage

Women seeking information on maternal health : Growing awareness

Despite changes in the average age of marriage among females, from 15 in 1961 to 21 years in 2001, many girls are still married off at a young age and many young mothers are vulnerable to early death. Such marriages occur in the rural parts of the country where even basic health facilities are not available.

According to Nepalese law, minimum marriage age for girls has been set at 18 years while it is 16 years with parental consent. If the boys and girls want to marry of their own accord the minimum legal marriage for boys is 21 and for the girls it is 16 years. In many ethnic groups, this is hardly ever followed and marriages take place at earlier ages.

The National Population Report 2002, published by the Ministry of Environment and Population, indicates that the age at marriage for both the males and the females has been increasing gradually over the years. The 1991-2001 decade has shown a remarkable change in the singulate mean age at marriage. The report reveals that this increase is due to increasing urbanization and education (including literacy) among men and women.

“This is a failure of our policies and programs. We are always perfect in formulating programs but our implementation part is always weak,” said Minister of Health Kamal Thapa. “The time has come to take certain drastic step to reduce the maternal mortality rate.”

Improved Infrastructures

With the assistance of MNH/Nepal, the Patan Hospital Birthing Center was strengthened and developed as a safe motherhood refresher training site for Assistant Nurses Midwives (ANM) and Staff Nurses. The government has also taken number of initiatives to improve the situation. UNICEF and UNFPA have been helping to train manpower, standardize national curricula and other facilities in the health centers throughout the country.

Despite the number of efforts, the health facilities are too small to meet the growing demand of the country’s population. Large sections of the rural population have yet to realize the need to visit the hospital during pregnancy.

The government has developed national safe motherhood polices, national maternity care guidelines and reproductive health protocols but it is yet to reduce the maternal mortality rate in the country. It is still risky to give birth to a child in rural areas.

“A safe motherhood service should constitute an integral part of human development. In line with global commitment, Nepal has developed the Safer Motherhood Strategy and Program for up to 2017. I am hopeful that the antenatal, delivery and postnatal care will be much strengthened by establishing Basic Emergency Obsetric Care in 137 primary health centers and comprehensive obstetric Care in 63 hospitals during this period,” said prime minister Thapa in his recent speech.

It will take decades before many other women like Rai stop dying from simple post natal complications. The situation seems to be worsening in remote rural areas where the conflict has deeply escalated, and where the life of the prospective mother is unsafe.