Measuring Maternal Mortality Rate in Nepal:

Initiatives and Efforts

Prepared ByNava Raj LamsalStatistics Officer

Central Bureau of StatisticsBranch Statistics Office,

NuwakotNepal

ESA/STAT/AC.219/18

Introduction Nepal is a land-locked country nestled

in the foothills of the Himalayas. Situated in the northern hemisphere, known as land of Mt. Everest and the birth place of Lord Buddha, Nepal is a tiny country. Though Nepal occupies only 0.03% and 0.3% of total land area of the world and Asia respectively, the country has an extreme topography and climate.

Contd. Topographically, Nepal is divided into three distinct

ecological zones: These are the mountain, hill and terai (plains). The mountain zone, ranges in the altitude from 4,877 meters to 8,848 meters above sea level and covers a land area of 51,817 square kilometers and only about 7 percent of the total population lives here. In contrast, the hill ecological zone, which ranges in the altitude from 610 meters to 4,876 meters above the sea level, is densely populated. About 44 percent of the total population lives in the hill zone, this covers an area of 61,345 square kilometers. Unlike the mountain and hill, the terai zone is the southern part of the country can be regarded as an extension of the relatively flat Gangetic plains of alluvial soil. The terai consist dense forest area, national parks, wildlife reserves, and conservation area. This area, which covers 34,019 square kilometers, is the most fertile part of the country and 49 percent of the population lives here.

Contd. According to the population Census

2001,the annual growth rate of population is 2.25 percent and the total population of the country in 2008 has reached about 26.9 million of which the proportion of male and female are almost equal. About one third of the populations (30.8%) live below poverty line and Ginni Coefficient 41.4.

Contd. Nepal has taken a Population Census every 10 years

since 1911.The latest census of Nepal was 2001 Population and Housing Census. Maternal Mortality Rate has been estimated after launching the program of the Safe Motherhood. Nepal Demographic Health Survey (NDHS) began collecting maternal mortality data through a series of questions designed to obtain a direct measure of maternal mortality. These questions were included for the first time in the 1996 Nepal family Health Survey (NFHS) and again ten years later in the 2006.

Contd. As regards the national statistical system of

Nepal, the present system is de facto decentralized. Central Bureau of Statistics (CBS) is the pivotal statistical agency within the national statistical system and it has 33 branch statistics office throughout the country. CBS was created in 1959 by virtue of Statistics Act, 1958 as the sole agency for the collection, consolidation, publication and analysis of statistics.

The data of Maternal Mortality Over the past two decades, the high level of maternal

mortality in developing countries has increasingly been recognized as an urgent public health concern. In 1987, the Safe Motherhood Conference in Nairobi, Kenya, drew attention to maternal mortality, and the issue has remained on the international agenda ever since. The Millennium Development Goal-Five (MDG-5) is to improve maternal health, with the target of reducing the 1990 maternal mortality ratio (MMR) by three quarters, by 2015. The Government of Nepal (GoN) is committed to achieving this goal and developed a national Safe Motherhood Plan of Action (SMPoA) in 1994. Since then, safe motherhood has been a national priority for Nepal.

Contd.

A Maternal Mortality and Morbidity (MMM) study was conducted in Nepal in 1998 as part of the determined focus on maternal mortality. The study was designed to gain a better understanding of the causes of death for women of reproductive age.

Contd. The two main sources of data

providing national level MMR estimates are the NDHS/NFHS and World Health organization (WHO). Other sources of data on maternal deaths in Nepal include surveillance data from Mother and Infant research Activities (MIRA) and the government Health Management Information System (HMIS) data.

Contd. The 1996 NFHS reported an MMR of 539 maternal

deaths per 100,000 lives births, with a 95 percent confidence interval. The 2001 NDHS did not attempt to measure maternal mortality and the 2006 NDHS reported and MMR of 281 maternal deaths per 100,000 live births. The point estimates of MMR suggest that maternal mortality has declined by 48 percent over the last ten years. The Government of Nepal has conducted the latest survey in 13 April 2008 to 13 April 2009 and found that the overall MMR for the eight districts is 229 per 100,000 live births, ranging from 153 to 301 by district. This is consistent with the 2006 NDHS survey data.

Contd. Maternal mortality ratio 1987-2009

Reference Year Ratio Per 100,000

Source

1991 515 NFHS,1991,MOH

1990-1996 539 NFHS,1996,MOH

1998 596-683 MMMS,1998,MOH

2006 281 NDHS,2006

2009 229 MMMS,2008/09,M0HP

Plan, policy and provisions Safe Motherhood was identified as a priority

programme in the GoN National Health policy 1991. A National Safe Motherhood Policy was formulated and endorsed by the Government in 1998. The policy placed emphasis on strengthening maternity care, including family planning services, at all levels of health care delivery system; enhancing technical skills of the health care providers at all levels; and strengthening referral services for emergency obstetric care. The major health plan and policies are summarizing below.

Conted. Long Term Health Plan-I1975-1990, National Health

Policy-1991,National Safe Motherhood Plan of Action1994-97,Long Term Health Plan-II1997-2017,National Safe Motherhood Policy-1998,Safe Motherhood Plan of Action2001-2015,National Safe Motherhood Plan2002-2017,Tenth Plan2002-2007,Nepal Health Sector Program Implementation plan2004-2009, National Policy for Skilled Birth Attendants-2006,National Safe Abortion policy-2006,Safe Motherhood and Newborn Health Long Term Plan2006-2017,Three Year Interim Plan2007-09

Conted. All these plan; policies and provisions are

based on the national and international commitments committed by the Government of Nepal such as CEDAW (articale12), CRC, ICPD (+5, 10) PRSP, BPFA (women and health) and MDGs(5). The Government of Nepal implemented to provide transportation package for the pregnancy women if she made delivery in the health institutions. Under this provision women can get Rs.500, Rs.1000. and Rs.1500 respectively in the teari, hill and mountain areas.

Maternal Health Care System

According to national guidelines maternal services aims to help families take appropriate decisions through health information and counseling, to provide basic antenatal and delivery services to all present women and to ensure referral and adequate obstetric care to high-risk mothers and obstetric emergencies. The maternal health care system in Nepal operates at various levels;

Contd. Household Community (About 48,000 FCHV) Sub health Post Health Post Primary Health Care Center District Hospitals Zonal and regional hospitals Central level hospital

Barrier to Maternal Health Care Despite substantial inputs over a number of years

from the side of the Nepal government and its safe motherhood partners, significant barriers still exist for women needing to seek maternal health care, on both supply and demand side.

Demand Side Barriers-Lack of understanding, Culture of Silence, Family and Social Restriction, Tradition Beliefs and Practices, Too Shy or Ashamed to Seek Care ,Distance to Health Facilities and Lack of Transport, Cost of Health Care,

Supply Side Barriers-Availability of Services and Referral, Quality of Facilities, Availability of Drugs and Suppliers, Availability and Ability of staff, Staff Attitude

Methods to estimate Maternal Mortality Rate

The maternal mortality ratio (MMR), which is obtained by dividing the age-standardized maternal mortality rate by the age-standardized general fertility rate, is often considered a more useful measure of maternal mortality because it measures the obstetric risk associated with each live birth. The most recent NDHS, 2006 uses a variant of the sisterhood approach called the direct sisterhood method. The sisterhood method obtains information by interviewing a representative sample of respondents about the survival of all of their adult sisters to overcome sample size problems. The direct approach relies on fewer assumptions and collects more information than the original indirect method, but requires larger sample sizes and the analysis is more complicated. The sisterhood method is a time of death measure rather than cause of death measure and hence identifies pregnancy related deaths rather than maternal deaths.

Contd. In 2000 WHO applied the observed

Proportions Maternal among Deaths of Females of Reproductive Age (PMDF) from the sisterhood data to the number of non-HIV female deaths aged 15to49 estimated to calculate maternal deaths. The MMR was then obtained by dividing total maternal deaths by the estimated of live births as reported in the United Nations Demographic Yearbook.

Contd. The recent study 2008-2009 followed the

following methodology, which covered both qualitative and quantitative aspects.

A community surveillance system Maternal Death reviews Rapid facility and staff competency

assessments Emergency Obstetric Care (EOC) monitoring Using Qualitative components, group

discussions and interviews

Conclusion The information is essential for informed policy

decisions, planning, monitoring and evaluation of programs on health in general and reproductive health in particular at both the national and regional levels. A long –term objective of the census and survey is to strengthen the technical capacity of government organizations to plan, conduct, process and analyze data from complex national population and health surveys. In Nepal, Series of Population census has been conducted since 1911 and 11th census is going to be conducted in the 2011 by the Central Bureau of Statistics.

Contd. In addition to the population census, different surveys

also conducted for the purpose to measure demographic features. The latest NDHS had been done in the 2006, data from this third survey, allow for comparisons of information database on demographic and health variables. The principle objective of this survey was to provide reliable data on fertility, child mortality, nutritional status, maternal mortality etc. Three questionnaires were administered: the household questionnaire, the women's questionnaire, and the men's questionnaire. The women's questionnaire was used to collect information from all women age 15-49 which is related to the maternal mortality ratio. Pregnancy histories were taken from all eligible women aged 15-49 years in the households sampled for the 2006 NDHS.

Contd. Since the national safe motherhood

programme was launched in 1997 and designated a (P1) priority programme, substantial financial and other resources have been invested in the effort to reduce the high national MMR. The 2006 NDHS indicated encouraging success, with much reduced MMR; however, a further analysis indicates this is not solely the result of improved care, as evidence shows modest progress in this respect, at best

Contd. Finally, the government of Nepal has made lots of

commitment such as CEDAW, BPFA and MDGs etc. nationally and internationally to empower the women and children. By using committed instruments plan, policy and program has been prepared. Under these programs reduction of maternal mortality is one of the most important national agenda. To make success national agenda without proper information is impossible. For this purpose, Government of Nepal has initiated to measure MMR through census, surveys and vital registration systems. Central Bureau of Statistics is one of the government agencies to collect, compile, analyses and dissemination of the data. It has planned to estimate MMR in the upcoming census 2011 which is 1st time in Nepal.

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