Maternal Health, Reproductive Health, Nepal

1. A Review on Global Situation of
Maternal Health: Progress,
Challenges and Ways Forward
Hari Prasad Kaphle
15PHPHLT 102
FHS, SHIATS, India

2. Introduction
• The term maternal health includes the health of women
during pregnancy, child birth and postpartum period.
• Every day 830 women die from preventable causes related
to pregnancy, childbirth and postpartum.
• 90% of all maternal deaths occur in developing countries.
More than half of these deaths occur in sub-Saharan Africa
and almost one third occur in South Asia.
• The MMR is 239 in developing countries while it is only
12 per 100 000 live births in developed countries in 2015
(WHO, 2015).

3. Introduction
• Globally, the MMR fell by 44% over the past 25 years (385 to
216 per lakh live births from1990 to 2015).
• The annual number of maternal deaths decreased by 43%
from 532 000 in 1990 to 303000 in 2015.
• The global lifetime risk of a maternal death fell from 1 in 73
to 1 in 180.

4. Global MMR in 2015: At a Glance

5. Regional Comparison in MMR 2015
0 100 200 300 400 500 600
Global
European Region
Western Pacific Region
Region of the Americas
South-East Asia Region
Eastern Mediterranean Region
African Region
216
16
41
52
164
166
542
Source: WHO, World Health Statistics 2016.

6. Trends of Maternal Mortality 1990-2015
WHO Regions 1990 1995 2000 2005 2010 2015 Change
%
African
965 914 840 712 620 542 44
Eastern
Mediterranean
362 340 304 250 199 166 54
South-East Asia
525 438 352 268 206 164 69
American
102 89 76 67 62 52 49
Western Pacific
114 89 75 63 50 41 64
European
44 42 33 26 19 16 64
Global
385 369 341 288 246 216 44
Source: WHO. Trends in maternal mortality: 1990 to 2015

7. MMR in South East Asian Countries 2015
0 50 100 150 200 250 300
DPRK
Thailand
Sri Lanka
Maldives
Indonesia
Bhutan
India
Bangladesh
Myanmar
Timor-Leste
Nepal
11
20
30
68
126
148
174
176
178
215
258
Source: WHO, World Health Statistics 2016.

8. MMR in South East Asian Countries 2015
Countries 1990 1995 2000 2005 2010 2015 Change%
Nepal 901 660 548 444 349 258 71
Timor-Leste 1080 897 694 506 317 215 80
Myanmar 453 376 308 248 205 178 61
Bangladesh 569 479 399 319 242 176 69
India 556 471 374 280 215 174 69
Bhutan 945 636 423 308 204 148 84
Indonesia 446 326 265 212 165 126 72
DPRK 75 81 128 105 97 82 -9
Maldives 677 340 163 101 87 68 90
Sri Lanka 75 70 57 43 35 30 60
Thailand 40 23 25 26 23 20 49
Source: WHO. Trends in maternal mortality: 1990 to 2015

9. Global causes of maternal death: a WHO
systematic analysis
• 23 eligible studies identified (published 2003–12)
• 417 datasets from 115 countries comprising 60799 deaths
included in the analysis.
• About 73% of all maternal deaths between 2003 and 2009 were
due to direct obstetric causes & 27·5% due to indirect causes.
• Haemorrhage accounted for 27·1%, hypertensive disorders 14·0%,
sepsis 10·7% , abortion 7·9% , embolism 3·2% , and all other
direct causes of death 9·6% . Source: Say et al 2015

10. ANC Coverage by WHO Region 2007-14
WHO Regions 1 ANC 4 ANC
African Region 77 48
Eastern Mediterranean Region 78 48
South-East Asia Region 77 70
Western Pacific Region 95 -
Region of the Americas 96 90
European Region - -
Global 83 64
Source: WHO, World Health Statistics 2015.

11. ANC in Coverage in SEA Countries 2015
Countries 1 ANC coverage 4 ANC coverage
Bangladesh 59 25
Myanmar 83 43
Nepal 58 50
Timor-Leste 84 55
India 75 72
Bhutan 74 77
Maldives 99 85
Indonesia 96 88
Sri Lanka 99 93
Thailand 98 93
DPRK 100 94
Source: WHO, World Health Statistics 2015.

12. Proportion of Birth Attendant by SBA 2015
0
10
20
30
40
50
60
70
80
90
100
AFR SEA EMR WPR AMR EUR Global
54
59
67
95 96 99
73
Source: WHO, World Health Statistics 2015.

13. Proportion of Birth Attendant by SBA 2015 in
SEA Countries
29
42
48
68
74 75 78
87
99 100 100
0
20
40
60
80
100
120

14. Births by caesarean section (%) in 2015
WHO Regions % of birth by C/S
2007-14
African Region 4
Eastern Mediterranean Region 22
South-East Asia Region 10
Western Pacific Region 25
Region of the Americas 38
European Region 25
Global 17
Source: WHO, World Health Statistics 2015.

15. Births by caesarean section (%) in 2015
Countries % of birth by C/S 2007-14
Bangladesh 19
Myanmar NA
Nepal 5
Timor-Leste 2
India 8
Bhutan 12
Maldives 41
Indonesia 12
Sri Lanka 31
Thailand 32
DPRK 13
Source: WHO, World Health Statistics 2015.

16. Inequities in postnatal care: a systematic
review & meta-analysis
• 36 studies were included in the narrative synthesis and 10 of them
were used for the meta-analyses.
• Compared with women in the lowest quintile of socioeconomic
status, the pooled odds ratios for use of postnatal care by women
in the second, third, fourth and fifth quintiles were: 1.14 (95% CI
: 0.96–1.34), 1.32 (95% CI: 1.12–1.55), 1.60 (95% CI: 1.30–1.98)
and 2.27 (95% CI: 1.75–2.93) respectively.
• Compared to women living in rural settings, the pooled odds ratio
for the use of postnatal care by women living in urban settings
was 1.36 (95% CI: 1.01–1.81).
Source: Langlois VE et al 2015.

17. Nepal: Urban-rural variation in maternal
health service utilization
Urban Rural Total
No of ANC visits
None 6.3 16.1 15.2
<4 times 21.9 36.2 34.7
≥4 times 71.8 47.7 50.1
Institutional delivery
Yes 71.3 31.6 35.3
No 28.7 68.4 64.4
Postnatal visits (at least one)
Yes 72.4 41.7 44.5
No 27.6 58.3 55.5
Source: Government of Nepal, NDHS 2011.

18. Barriers for maternal health service utilization in Nepal
• The study concluded that lack of awareness, remoteness, large
geographical distances, significant influence of other family
members, low autonomy and decision-making power are factors
that impede use of maternal health services.
• Similarly structural barriers are financial barriers and lack of
awareness of the financial incentives, time barriers, especially
related to travelling time and infrastructure, in addition to
organizational barriers related to the shortage of SBAs in rural
areas.
Source: Holst C 2014.

19. Barriers for maternal health service
utilization in Nepal
• The study found that inadequate knowledge of the importance of
services offered by skilled birth attendants (SBAs), distance to
health facilities, unavailability of transport services, and poor
availability of SBAs as major barriers to skilled birth care.
• Other barriers were poor infrastructure, meager services, inadequate
information about services/facilities, cultural practices and beliefs,
and low prioritization of birth care.
• Moreover, the tradition of isolating women during and after
childbirth decreased the likelihood that women would utilize
delivery care services at health facilities.
Source: Onta et al 2014

20. Ways Forwards
The global strategy for women’s, children’s and adolescents’ health
(2016-2030)
• An Updated Global Strategy For The Post-2015 Era derived
from SDGs an updated version of MDGs.
• Vision: By 2030, a world in which every woman, child and
adolescent in every setting realizes their rights to physical and
mental health and well-being, has social and economic
opportunities, and is able to participate fully in shaping
sustainable and prosperous societies

21. Survive: End preventable deaths

22. THRIVE: Ensure health and well-being

23. TRANSFORM: Expand enabling environments

24. Nepal and SDGs for Maternal Health
Indicators 2015
Status
2017 2020 2022 2025 2030
Maternal mortality ratio (per
100,000 live births)
258 151 127 116 99 70
Proportion of births attended
by SBA (%)
55.6 62.1 68.5 72.8 79.3 90
Four times antenatal (ANC)
coverage (%)
59.5 65.2 70.9 74.7 80.5 90
Postnatal (PNC) coverage (%) 57.9 63.9 70 74 80 90
SDGs indicators and targets for Nepal (2014–2030)
Source: National Planning Commission, 2015

25. How we can improve quality in
Maternal Health Services?
Source: Austin et al, 2014

26. Evidence-based health interventions for
improvement of maternal health
Pre-pregnancy interventions
1. Information, counseling and services for comprehensive sexual and
reproductive health including contraception
2. Prevention, detection and treatment of communicable & non-
communicable disease and STIs & RTIs including HIV, TB and syphilis
3. Iron/folic acid supplementation (pre-pregnancy)
4. Screening for and management of cervical and breast cancer
5. Safe abortion (wherever legal), post-abortion care
6. Prevention of and response to sexual and other forms of gender-based
violence
7. Pre-pregnancy detection and management of risk factors (nutrition, obesity,
tobacco, alcohol, mental health, environmental toxins) and genetic
conditions

27. Evidence-based health interventions for
improvement of maternal health
Pregnancy interventions (antenatal)
1. Early and appropriate antenatal care (four visits), including
identification and management of gender-based violence
2. Accurate determination of gestational age
3. Screening for maternal illness
4. Screening for hypertensive disorders
5. Iron and folic acid supplementation
6. Tetanus immunization
7. Counseling on family planning, birth & emergency preparedness
8. PMTCT of HIV, including with antiretrovirals
9. Prevention and treatment of malaria including insecticide treated nets
and intermittent preventive treatment in pregnancy
10. Smoking cessation

28. Evidence-based health interventions for
improvement of maternal health
Pregnancy interventions (antenatal)
11. Screening for and prevention and management of sexually transmitted
infections (syphilis and hepatitis B)
12. Identification and response to intimate partner violence
13. Dietary counselling for healthy weight gain and adequate nutrition
14. Detection of risk factors for, and management of, genetic conditions
15. Management of chronic medical conditions (e.g. hypertension, pre-existing
diabetes mellitus)
16. Prevention, screening and treatment of gestational diabetes, eclampsia and pre-
eclampsia(including timely delivery)
17. Management of obstetric complications (preterm premature rupture of
membranes, macrosomia, etc.)
18. Antenatal corticosteroids for women at risk of birth from 24-34 weeks of
gestation when appropriate conditions are met
19. Management of malpresentation at term

29. Evidence-based health interventions for
improvement of maternal health
Childbirth
1. Facility-based childbirth with a SBA
2. Routine monitoring with partograph with timely and appropriate care
3. Active management of third stage of labour
4. Management of obstructed labour including instrumental delivery and C/S
5. Caesarean section for maternal/ foetal indications
6. Induction of labour with appropriate medical indications
7. Management of post-partum haemorrhage
8. Prevention and management of eclampsia (including MgSO4)
9. Detection and management infections (including antibiotics for C/S)
10. Screening for HIV and prevention of mother to child transmission
11. Hygienic management of the cord, including use of chlorhexidine where
appropriate

30. Evidence-based health interventions for
improvement of maternal health
Postnatal (mother)
1. Care in the facility for at least 24 hours after an
uncomplicated vaginal birth
2. Promotion, protection and support of exclusive
breastfeeding for 6 months
3. Management of post-partum haemorrhage
4. Prevention and management of eclampsia
5. Prevention and treatment of maternal anaemia
6. Detection and management of post-partum sepsis
7. Family planning advice and contraceptives

31. Evidence-based health interventions for
improvement of maternal health
Postnatal (mother)
1. Routine post-partum examination and screening for
cervical cancer in appropriate age group
2. Screening for HIV and initiation or continuation of
antiretroviral therapy
3. Identification of and response to intimate partner violence
4. Early detection of maternal morbidities (e.g. fistula)
5. Screening and management for post-partum depression
6. Nutrition and lifestyle counseling, management of inter-
partum weight
7. Postnatal contact with an appropriately skilled health-care
provider, at home or in the health facility, around day 3,
day 7 and at 6 weeks after birth

32. Evidence-based health interventions
for improvement of maternal health
POSTNATAL (newborn)
1. Care in the facility for at least 24 hours after an uncomplicated vaginal birth
2. Immediate drying and thermal care
3. Neonatal resuscitation with bag and mask
4. Early initiation of breastfeeding (within the first hour)
5. Hygienic cord and skin care
6. Initiation of prophylactic antiretroviral therapy for babies exposed to HIV
7. Kangaroo mother care for small babies
8. Extra support for feeding small and preterm babies with breast milk
9. Presumptive antibiotic therapy for newborns at risk of bacterial infection
10. Management of babies with respiratory distress syndrome
11. Detection and case management of possible severe bacterial infection
12. Management of newborns with jaundice
13. Detection and management of genetic conditions
14. Postnatal contact with a skilled health-care provider, at home or in the health
facility, around day 3, day 7 and at 6 weeks after birth

33. Health sector interventions for
improving maternal health
• Increasing Access to Family Planning Information and Services
• Improving Coverage and Quality of Prenatal Care
– Prevention of malaria (chemo prophylaxis).
– Detection and management of anemia (oral or injectable iron).
– Treatment of hookworm infestation.
– Early detection and management of pregnancy-induced hypertension
– Screening for sexually transmitted infections and HIV
– Immunization for primary prevention of neonatal and maternal tetanus
• Improving Management of Delivery, Immediate Post delivery, and Neonatal
Complications
• Improving Delivery at Home by a Nonprofessionally Trained Provider
• Promoting Skilled Attendance at Home and in Facilities
• Improving Availability of Health Facilities Providing Emergency Obstetric Care
• Strengthening Referral Services
• Coordinating Reproductive Health Services and Management of STIs, HIV, and
AIDS

34. Interventions outside the health sector for
improving maternal health
• Enabling Policies and Political Commitment
• Enhancing Community Participation
• Promoting Cross-Sectoral Linkages

35. References
1. Austin A, Langer A, Salam RA, Lassi ZS, Das JK, Bhutta ZA. Approaches to improve the
quality of maternal and newborn health care: an overview of the evidence. Reproductive Health
2014 11(Suppl 2):S1. doi:10.1186/1742-4755-11-S2-S1.
2. NPC. Sustainable Development Goals, 2016-2030, National (Preliminary) Report. Government
of Nepal, National Planning Commission, Kathmandu, Nepal; 2015.
3. Every woman, every child, UN. The global strategy for women’s, children’s and adolescents’
health (2016-2030): Survive, Transfer, Thrive. UN Sustainable development goals.;2015.
4. Lule E, Ramana GNV, Ooman N, Epp J, Huntington D, Rosen JE. Achieving the Millennium
Development Goal of Improving Maternal Health: Determinants, Interventions and Challenges.
World bank: March 2005.
5. Holst C. Use of skilled birth attendants in Nepal: A study of influencing factors, structural
barriers and government strategies and interventions.(M. Phil Thesis). Faculty of Social Sciences
and Technology Management, Norwegian University of Science and Technology. Oslo, Norway;
May 2014.

36. References
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