Nepal’s reported maternal mortality rate as of 2021 is 151 per 100,000 live births. Lumbini province has the highest maternal mortality and Bagmati province has the lowest (A report on Maternal Mortality, National Population and Housing Census, 2021). The rate of institutionalized delivery has increased from 57% in 2016 to 79% in 2022 (NDHS Report). Maternal health is a broad topic that encompasses many factors for women and their families. To achieve proper maternal healthcare in Nepal, key issues that arise in all three stages of childbirth need to be addressed. They are the antenatal phase, the intrapartum phase, and the postnatal phase.

Antenatal phase

The antenatal phase starts after conception and until childbirth. The first check-up must be done as soon as the pregnancy is recognized. Following this, the government of Nepal  recommends that the pregnant  mother  should visit at least 8  ANC contacts throughout  her pregnancy period. Additionally, mothers should seek additional help if any complications occur. However, a majority of Nepali mothers in rural areas face accessibility issues. A single check-up in a health post can be an hour or more of walking. This takes time from the day in places where pregnant women are still expected to complete most household chores like cooking, cleaning the house, and taking care of other children in the family.

A healthpost at Masta RM, Bajhang District with birthing facilities. (Image: Pankaj Thapa)

The appointment is a gamble as health posts may only be able to provide basic facilities or be out of service due to load-shedding when a pregnant woman faces complications. This becomes a dangerous journey for women and taxing for their bodies.

Aawaaj News interviewed Mrs. Dammari Bhatta, a health and social work major who devotes her time to ensuring health among pregnant women and newborn children in Dadeldhura. She has worked in maternal health through NGOs like RUWDUC in awareness programs like 1000 day mother. She elaborates how travel is the main challenge for mothers in Dadeldhura; many times, their husbands are employed in India and cannot accompany them.

Some local governments distribute Rs 150 – 200 as transport fare to such families, but that is not enough for families to reach the more advanced health center in Dhangadhi for multiple checkups. Besides, Mrs. Bhatta mentions that the families’ travel, accommodation, and medical cost could amount to Rs7000 or more. This is a reason low-income families cannot access proper prenatal care. Unfortunately, 17% of maternal issue-related mortality accounts for the mother’s death on the way to or back from the health facilities   (A report on Maternal Mortality, National Population and Housing Census, 2021).

Nutrition is another important aspect of maternal health. According to the Oregon Health and Science University, consuming nutritious food leads to optimal fetal growth, better outcomes in childbirth, and perinatal and long-term health benefits to both mother and child. In rural Nepal, although families know the nutrition requirements for pregnant women, they cannot fulfill them due to low-income sources and distance from the market.

For a deeper delve into the topic, we interviewed Mrs. Laxmi Pandey. Mrs. Pandey has a degree in nursing and sociology and is currently a part of the health ministry’s maternal and newborn health section. She elaborated on the availability of folic acid tablets in rural Nepal. Consuming folic acid pills can potentially prevent neural tube defects and birth defects such as anencephaly (related to the brain) and spina bifida (connected to the spine). Iron and Folic Acid supplements   are provided to pregnant women free of cost from the government. Different wards in different areas also have other initiatives like distributing eggs, chickens, or hygiene products to motivate women to visit health centers for a checkup.

Intrapartum phase

Moving on to the intrapartum phase, which consists of labor and the baby’s actual birth? According to Mrs Pandey, of the total number of deaths related to pregnancy complications during delivery, an estimated 26% are attributed to home births. There is an increased risk of life-threatening infections, postpartum hemorrhage, and lack of treatment for hypertension. Mrs. Bhatta mentioned that communities in Dadeldhura have a traditional mindset on childbirth and believe that women can deliver their child at home without complications as it has been an ongoing practice in the villages. Besides, to reiterate, it would be a long and expensive journey to the hospital and especially dangerous if the woman goes into labor at night. To tackle this, Mrs. Pandey also mentioned an ongoing program, at least 2 post natal care home visit programs (3 days and 7-14 days of delivery) with health workers which  is helpful  to identify the health status of postnatal mothers and their babies.

Institutional birth refers to giving birth in a health facility under supervision and assistance from trained health personnel. This has been already mentioned above as institutional delivery However, 57% of maternal issue-related deaths occur in health facilities; this could be a result of arriving too late to the health centers or the lack of equipment and qualified health workers to treat complications in the facilities.

In the interview, Mrs. Pandey also mentioned this could be due to demotivated employees in the health facilities as their work is less acknowledged or degraded by the media for not being advanced. To combat the geographical challenges, some hilly and mountain districts of Nepal can now use the helicopter service to transport pregnant and postnatal mothers to the advanced health facilities during emergencies. One of these villages is Jogbuda in Dadeldhura.

Mrs. Bhatta talked us through the process of women from Jogbuda using the helicopter service during labor to reach the health centers in Dhangadhi. The exact process also applies to other villages that use the helicopter service. She explained that the woman’s family first needs to contact their local ward; if the network is unavailable, the pregnant woman has to get to the ward by walking in her condition. The ward then contacts the respective municipality (nagarpalika) which then has to reach the mayor. The mayor can finally contact the institution and arrange a helicopter ride for the woman to reach the health center. The helicopter journey typically lasts for 4 hours during good weather. By this time, the woman may have experienced heavy bleeding, exhaustion, intense labor pain, and other complications.

Families only have information on ambulance services if they are referred to from Dhangadhi which is rare in Jogbuda.

Postnatal phase

Image: National Population and Housing Census 2021: A Report on Maternal Mortality Image

Finally, the postnatal phase refers to the period immediately after childbirth. It is critical to maintain the health of the mother and newborn during this time. Postpartum hemorrhage (PPH) is another prominent cause of death among new mothers in Nepal. It occurs when a woman experiences heavy bleeding after birth. The treatment for PPH needs to be done by a medical professional through medication, manual massage of the uterus, or removal of remaining placental pieces from the uterus. Blood pressure levels also play a vital role in a woman’s well-being, and hypertension is a cause of death for many women. Thus, blood pressure levels should be closely monitored.

In the case of institutional birth, the journey back home can be dangerous as PPH can occur up to 42 days after childbirth. Proper nutrition needs to be emphasized in this stage. Although awareness campaigns in these areas have informed people on nutritious food and the importance of it, many families cannot afford such food items. They can hardly access it due to their geographical location.

In most communities, women are expected to work on household tasks immediately after giving birth. This can deteriorate women’s health further since they cannot fully recover after childbirth.

Ms. Dummari Bhatta elaborated on the “Mahila Swasthya Samiti” groups in each local ward in her interview. These groups are formed by local women who try to care for each other during pregnancy. This involves helping pregnant women and new mothers with hygiene, providing health supplements like iron pills, and helping them with chores in the house.

Solutions

As per the report above, Aawaaj also inquired about solutions and initiatives that can be implemented on a government level to reduce maternal mortality and achieve better maternal health in Nepal. The SDG 3 targets for Nepal include reducing maternal mortality to 70 per 100,000 live births by 2030. Mrs. Bhatta emphasized the need for more awareness programs on maternal health by provincial governments, including counseling for pregnant women’s family members. This ensures that pregnant women are expected to work less and plan out health checkups and delivery methods beforehand to prevent complications.

Birthing facility in Masta RM, Bajhang District (Image: Pankaj Thapa / Aawaaj News)

Mrs. Bhatta believes birth at home should be reduced to 0 and more health centers should be established in rural areas within shorter distances from communities. She advocates for economic empowerment among women so they can support themselves during pregnancy and afford more nutritious food financially.

Mrs Pandey aims to launch ultrasound programs through her faculty in rural areas to make routine checkups more accessible for women in rural areas. Currently, in 20 districts of hilly regions “maternity waiting homes” have been built to facilitate pregnant women for days or weeks if needed. These homes have free access to skilled health workers, provision of nutritious food and supplements for pregnant women.