There are many reasons cited for the sharp reduction in Nepal’s maternal mortality rate (MMR), from 901 per 100,000 live births to less than 240.
Among them are trained community health volunteers even in the remotest village, and the spread of the road network that allows women with complicated pregnancies to be taken to hospital.
But perhaps the greatest factor is the rise in female literacy in the same period which in turn reduced the total fertility rate, and raised the average age of marriage through awareness and empowerment.
However, an MMR of 240 is still unacceptably high—it translates into 3 deaths at childbirth every day, 1,200 every year. For comparison, only two mothers out of 100,000 die at childbirth in Norway, and the figure for Sri Lanka is 30.
Besides, Nepal has to reduce its MMR to 70 in the net nine years to meet the UN’s Sustainable Development Goals target. The country has already failed to meet the interim target of reducing MMR to 125 by 2020.
The worrying thing is that the graph for maternal mortality has now flat-lined, mainly because government hospitals in the districts are under-equipped, under-staffed and under-funded. Many other families cannot afford delivery in private hospitals.
The latest figures for 2020 have not come in, but the Covid-19 crisis may have even increased the maternal mortality rate because fewer mothers could have institutional delivery. In fact Nepal’s first Covid-19 fatality in May was a mother from Sindhupalchok who had just given birth, but her family could not get an ambulance to take her to hospital during the lockdown.
Yet, if we probe the reasons for past progress it will show us the path forward. One of the factors contributing to the drop in MMR since 1990 was that the percentage of skilled birth attendants in rural health facilities went up from 4% to 53%.
In the meantime, as the Saglo Samaj report shows, the President’s Program for Women’s Upliftment has been conducting free emergency airlifts of post-partum mothers in remote areas facing life-or-death situations at childbirth.
The eligibility process is complicated for families who do not know how to work the system, but in the past two years, the program has conducted 170 emergency rescues and saved the lives of many mothers and babies.
Impressive as this is, it is not a sustainable way forward. The focus should be on decentralising medical care and making it the responsibility of provincial and municipal governments.
The emphasis must be on primary health care that can prevent communicable diseases through awareness, and treat most common surgeries like broken bones, and caesarian operations at the local level.
We have seen how hospital buildings are not enough, those structures need basic equipment like x-rays, anaesthesia machines, surgical units, and capable, motivated medical staff to use them.
Institutional delivery is not the answer if maternity wards of hospitals are poorly-staffed, cannot conduct safe delivery in complicated cases, or do not have nurses for ante- and neo-natal care.
A family physician who can perform basic orthopaedics, or deliveries including c-sections, can be more valuable than a specialised but expensive hospital that few can afford.
Nepal should already have been on a war-footing in meeting the MMR 70 target by 2030, and we have no time to lose. Action must be focused on the hotspots for maternal deaths, including districts in Far-western and Karnali Provinces, and Province 2 with community-based midwife training and district birthing facilities that have life-saving services 24/7.
So far, we have seen no strategy or a sense of urgency on the part of the Ministry of Health to meet the SDG target on reducing the maternal death rate. In the past year, Covid-19 has sucked much of the oxygen out of even existing efforts to upgrade medical care to make it more affordable and accessible. Pilot health insurance schemes are isolated success stories.
The story of 31-year-old Rejiya Nepali of Bajura encapsulates the human tragedy of many mothers who have to give up their lives to give birth to new lives. Nepali Times reported last year about how the mother of four in a remote village in Bajura was taken in a stretcher to a nearby health post after prolonged labour.
She gave birth along the way to a baby boy. But there was no one at the health post, and Nepali was being taken to the house of an Auxiliary Nurse Midwife. She died along the way.
Three other mothers died during childbirth in just that one Bajura village that month.
Saving one mother at a time, Bikash Gauchan
Nepal’s air ambulances saves mothers, Nepali Times