Goond Morning, I am Sharad from Nepal. I am presenting an overview of maternal health status in Nepal. This is the map of Nepal. Nepal is situated between two big countries, China in the North and India in the West, South and East.
This slide shows population structure of Nepal. As can be seen from pyramid, Nepal is a country with rapidly growing population. Projected population of Nepal for 2010 is 28.04 million.
According to the population census 2001, population growth of Nepal is 2.25 % per year, TFR is 3.1, median age of population is 20 and Mean age at marriage is 19.5 years.
This slide shows organization structure of ministry of health. Department of Health Services is one out of three departments under Ministry of Health. Under the DoHS there are 7 divisions and 5 Centers. Family Health Division (FHD) is responsible for the implementation of Maternal Health Program at the central level. At the regional level, we have 5 regional health directorates, 5 regional/sub-regional hospitals, 5 regional training centers and 5 regional medical stores. At the Zonal level, we have 10 zonal hospitals. At the district level we have 75 district health/public health offices and 65 district hospitals. At the electoral constituency level we have at-least one primary health care center. At the VDC level we have either a Health Post or a Sub-Health Posts. At the community level, we have Female Community Health Volunteers (FCHV), Primary Health Care Out-reach Clinic (PHC,ORC), and EPI Outreach Clinics.
This slide shows existing government health infrastructure from Central-level to community level
This slide shows the MDG target and present status of maternal health indicators. To attain MDG Nepal has to attain MMR of 134/100,00 LB, SBA delivery of 60%, CPR of 67% and TFR of 2.5. In all these indicators, Nepal is behind the MDG target but the trend of these indicators indicate that we are in track to attain MDG.
This slide shows a trend of process indicators. The figure indicates that Nepal has been able to gradually increase % of delivery in Basic or Comprehensive Emergency Obstetric Care Centers, Met Need of EOC and Met Need of C/S. As all these indicators are the proxy to MMR, we can therefore say that MMR has also been decreasing in Nepal over the last decade.
Improvement in maternal health indicators became possible because of various supply and demand side interventions. We have increased CEOC centers from 34 in 2004 to 93 in 2009, BEOC were increased from 13 to 105 in the previous five year period. Similarly we have been able to substantially increase the number of birthing centers and Safe Abortion Service sites over the last five year period.
Number of trained Skilled Birth Attendants, SBA and SAS training sites have also been increased.
This slide also shows the ongoing interventions towards health infrastructure development.
This slide shows the increasing number of reported deliveries by health worker. The figure further shows that the home delivery by health worker has started declining.
This table shows the trend of macro level indicators affecting maternal mortality. Positive trend of these indicators justifies the substantial decline in Maternal Mortality in Nepal. For example, PMDF has declined from 27% in 1996 to 11% in 2008, similarly % of SBA delivery has increased from 9% to 29% over the last decade. GDP per capita has also increased over the same period.
This table shows the level of MMR estimated from two sources; the Model-Based MMR and MMR obtained from Sisterhood method. These are the only two methods estimating MMR in Nepal, and provide only national level estimates. Population Census of Nepal 2011 has also included questions to estimate MMR in Nepal, this will provide sub-national level of MMR. The MMR obtained from these two sources are very different. The point estimate of MMR obtained from survey is much lower than the model based MMR. There is therefore a debate between these two estimates.
Even though the two methods of estimating MMR provided two different estimates, both estimates indicate that Nepal is in track to attain MDG. Model based MMR estimate indicates that Nepal has been able to reduce MMR by 54% in 2006 from the level of 1990. The survey estimate also indicates that MMR has been reduced by 52% in 2006 from the MMR of 1990. Both the estimates indicate that Nepal is in track to attain MDG. There are however few questions, which I would like to ask for clarification. As the CI of model based MMR in 2005 and survey based MMR in 2006 overlap, can we say that there is no significant difference between MMR obtained by two methods? The PMDF obtained by regression model has been reduced significantly from 41% in 1990 to 22% in 2005 but the confidence interval of MMR overlaps between the two period, why? There is however consistency in the PMDF and MMR obtained by Sisterhood method. For example while PMDF significantly reduced from 27% in 1990 to 18% in 2006, the MMR between the period also significantly decreased (as the CI do not overlap).
Maternal Helath in Nepal_Mukesh Mishra
Maternal Health Status in Nepal By Mukesh Kumar Mishra
Nepal’s Population : At-A-Glance Population (2010) 28,043,744 Population growth (2001) 2.25% Population under age 15 (2001) 39% Median age of population (2001) 20 Crude birth rate (2008) 27.7 Crude death rate (2008) 8.3 Total fertility rate (2006) 3.1 Mean age at marriage (2001) 19.5
Government Health Infrastructure Central Hospital 8 Regional Health Directorate 5 Regional Hospital 3 Sub-Regional Hospital 2 Regional Medical Store 5 Regional Health Training Center 5 Zonal Hospital 10 District Public Health Office 15 District Health Office 60 District Hospital 65 Primary Health Care Center 214 Health Post 679 Sub-Health Post 3134 FCHV 48549 PHC Outreach Clinic 13811 EPI Clinic 16260
Targets for MDG and Present Status Maternal Health in Nepal Indicators SMNH LTP (2017) MDG (2015) Present Status of Nepal MMR 134 / 100,000 LB 134 / 100,000 LB 281 per 100,000 LB (NDHS 2006) 229 per 100,000 LB (NMMM study in 8 districts (2008/09) Delivery by SBA 60% 60% 28.8 % (NFHP 2009) Institutional Delivery 40% 26.7% (NFHP 2009) Contraceptive prevalence rate 67% 48% (NHDS 2006) Total Fertility Rate 2.5 3.1 (NHDS 2006)
Progress in Service Sites Service Sites 2004 2007 2008 2009 CEOC 34 51 79 93 BEOC 13 68 90 105 Birthing unit in PHCC 89 168 167 148 Birthing unit in HP NA 219 301 406 Birthing Unit in SHP NA 35 64 137 SAS sites 12 206 245 331
Training of Health Personnel Training 2008 2010 SBA Training 350 1686 C/S Training Sites 12 Expansion of SBA Training Sites 16 SAS Training 192 <ul><ul><li>961 </li></ul></ul>
Infrastructure (Health Facilities) Development Type of Services Construction On-going Planned for 2010 CEOC Sites 9 4 BEOC sites 9 6 SAS sites 1 6 BEOC (PHCC) 57 15 Birthing Center (HP) 90 200 Birthing Centers (SHP) 32 35 TOTAL 198 266
Number of Deliveries By Health Personnel (2004 - 2008)
Trend of Covariates of Maternal Mortality * Nepal Family Health Survey **Nepal Dempgraohic & Health Survey, 2001 *** Nepal Dempgraohic & Health Survey, 2006, **** Mid-term Survey for NFHP II + Statistical Pocket Book, Nepal, 2006 ++ Statistical Pocket Book, Nepal, 2008 +++ WHO/UNFPA/UNICEF, 2000, ++++ NMMM Study 2008/2009 Indicators Year of Publication 1996 2001 2006 2008 % of maternal among death of women of RH Age (PMDF) 27.1 * 24 +++ 18 *** 10.7 ++++ GFR per 1000 birth 162 * 148 ** 117 *** 108 **** GDP Per Capita at current price (NRS) 13343 + 17863 + 27538 ++ 34732 ++ % of SBA Delivery 9 * 11 ** 19 *** 29 ****
Trend of MMR estimates in Nepal Source and Method of MMR Estimate Reference Period PMDF MMR 95% CI Lower Upper WHO & UNICEF (Model Based) 1990 41% 1538 1121 1989 NFHS, 1996 (Direct Sisterhood) 1990-1996 27% 539 392 686 WHO, UNICEF, UNFPA & World Bank Estimate (Regression Model Based) 1995 23% 830 580 1100 WHO, UNICEF, UNFPA & World Bank Estimate (Regression Model Based) 2000 24% 740 440 1100 WHO, UNICEF, UNFPA & World Bank Estimate (Regression Model Based) 2005 22% 830 290 1900 NDHS, 2006 (Direct Sisterhood) 2000-2006 18% 281 178 384 NMMM 2008/2009 Study (8 district Average with modified RAMOS) 2008 11% 229 153 301 WHO, UNICEF, UNFPA & World Bank Estimate (Regression Model Based) 2008 9% 380 210 620
% Reduction of MMR In 2006 Relative to 1990 CI Overlap, No Difference ?? Model Based PMDF Has Been Significantly Reduced But Why The Confidence Interval Still Overlap Between 1990 and 2005 ?? Source and Method of MMR Estimate 1990 2006 % Reduction Remarks WHO & UNICEF (Model Based) 1538 830 54% On Track for ¾ Reduction by 2015 Direct Sisterhood 539 281 52% On Track for ¾ Reduction by 2015 CI of MMR (Model Based) 1121-1989 290-1900 CI of MMR (Direct Sisterhood) 392-686 178-384 PMDF (Model Based) 41% 22% 54% PMDF (Direct Sisterhood) 27% 18% 67%