Study shows  Nepal government of Nepal, U.S. Agency for International Development (USAID), and UK Department  of international Development (DIFID) jointly launched the findings of the 2009 Maternal Mortality and Morbidity study. The current study is the follow up of the 1998 Maternal mortality and Morbidity study done to investigate factors associated with maternal and morbidity in Nepal, particularly the causes of maternal morbidity.

Conclusion:

This study is the outcome of considerable effort by the government of Nepal, supported by DFID and USAID to better understand the level and variation of maternal mortality in Nepal and identify the principal contributory factors to maternal deaths. Comparision of the findings with those of a similar study conducted in 1998 in decaded area where previous intervention have worked, where efforts need to be sustained of accelerated  and where they need to be refocused. Supported by other sources of information, this suggested significant improvement over the past 10 years in access to routine and life saving   are and prevention of maternal deaths.  The feeding also aligns with the NDHS 2006 MMR estimate, which indicates Nepal in on track to meet the fifth millennium development goal. This is a major achievement in a resource poor setting that has suffered from political instability over much of this period. However, the stories of the hundred of women who died during this study period are evidence of many issues that remind to be tackled. 

In 1998, maternal causes announced for one in five deaths of women of reproductive age and were the leading cause of death among these women by ICD-X category. Data from the 2008/09 study indicate a reduction to around one in ten, to only the third leading cause by ICD-X.The MMR, calculated from  actual data on live births and maternal deaths in the eight study districts, was 299 per 1,00000 live births, a similar result to the estimate for the 2006 NDHS. This validates the NDHS methodology as providing a robust national figure, suggesting real and significant improvements in maternal health over the past 10/5 years, rather than that that used by the World Health Organization in 2005, which gave a far higher MMR estimate MMR results for individual districts range from 153 to 301, we further analysis showing older women and some ethnic groups are at significantly greater risk of maternal death.
 
Less encouraging is the finding that suicide is now the leading single causes of death among women of reproductive age- accounting for 16% of all deaths. This shocking finding calls for immediate action to better understand the causes and contributory factors and develop policies and interventions to address them.  In particular a high number (21% of total) of suicides by young women, 18 years and under indicates a need to target youth.  

In 1998, only 21% of maternal deaths occurred in a facility, compared with 67% at home. In contrast, this study found 41% of deaths occurred in facilities, a clear indication of a change in utilization of facility services, albeit often too late, as it was reported that most women with complications arrived at the facility in a critical state. Evidence from qualitative data supports this conclusion, as communities’ demonstrated increased recognition of the importance of seeking care quickly from the formal sector in the event of complication. Data from the 2006 NDHS also suggest increased use of facility care, although still with a focus on treatment of complication, often as a last resort, rather than normal delivery care. These findings indicate balance of the contributory factors to maternal deaths is moving to include more supply side factors, so that efforts to further reduce maternal mortality most focus on improving quality of care and speed of response within facility, combined with continued efforts at community level to improve recognition of danger signs, improve planning for emergencies and reduce barriers to access, including cost. The new free delivery care policy (Aama Programme, 2009) could have an important impact in this area.

The reduction of percentage of deaths due to hemorrhage (to 24%, from 46% of all maternal deaths in 1998) suggests improvements in recognition and treatment of bleeding (in particular postpartum). Appropriate knowledge and routine use of oxytocics for third stage of labour, plus the relatively good stocks found at most facilities, reflects the success of efforts to improve management of PPH, partly as a result of its recognition as a leading cause of death in the 1998 study. In addition, the number of instances in which lack of access to blood was identified as a major contributory factor to death was found to be significantly lower. Where there is still scope for improvement, government commitment through the 2006 revised safe blood policy appears to have made a difference.

Nearly a third of facility deaths were due to eclampsia, despite its forming a relatively small percentage of all complications treated. This findings and supporting evidence highlights important shortcomings in access to life-saving magnesium sulphate, with many facilities reporting periods when it is out of stock. This urgently needs attention.

Despite the widespread introduction of safe abortion services across the country, the percentage of women dying from unsafe or incomplete abortion has almost doubled between the two studies, although this may be partly attributable to increased reporting of cases since abortion was legalized in 2002.The percentage of facility deaths due to abortion also increased, from 10% to 14%, but the percentage of abortion complications at EOC facilities has dropped significantly, to 28%, from 54% f al complications in 1998.sThis is a significant finding, suggesting that, although fewer abortion complications are presenting at facilities, they are more serious and / or their management is not adequate. Findings indicate that a considerable percentage of provides continue to routinely use D & C rather than the internationally recommended MVA method, and that some non-government facilities do not even have MVA sets in stock. Competency assessments also indicated important gaps in the knowledge and skill of some providers. This highlights a need to maintain and increase support for improving access to safe abortion services and post abortion care.

The voices of women who have been pregnant and accessed services, and their families,neighbours and service providers, highlights important changes in behavior and attitude over the past decade. These includes a very clear (though not universal) increase in uptake of antenatal care and changes in attitudes to care of women during pregnancy, including improved diet and avoidance of heavy work. The use of traditional healers appears less prominent than in 1998, but their status in many communities as an early point of consultation remains an important contributory delay in accessing formal care. While home delivery remains the preferred option for many women, service providers report increased utilization of facility services, especially for complications. However, lack of recognition of problems and slow decision- making remain significant delays in many cases. Combined with long distances, lack of transport, cost, and lack of capacity  to treat serious complications at the closest facilities, this can mean the decision to deliver at home and only go to a facility in the event of an emergency is risky.

A number of important issues were identified, which comprise access to prompt high quality care and contribute to poor maternal outcomes. Many are similar to those found in 1998 but there are important changes in their magnitude and extent. The practice of evidence based care was found too broadly reflect the availability of skilled birth attendants, indicating a positive impact of government investment in skilled birth attendance training. However, the examples seen of lower than acceptable knowledge and / or competence among providers highlight the need to further increase efforts to train and support providers as skilled birth attendants. The well known issues of staff availability and transfer continue to negatively affect the provision of skilled care, particularly CEOC, at facilities built and equipped to provide this level of service, highlighting the vulnerability of systems even after the required inputs are provided and services established. Jumla district hospital is an example of this, as a newly refurbished CEOC centre had to be downgraded to BEOC due to transfer out of the surgically skilled doctor. Poor referral networks are also identified as a key weakness and contributory factor in many deaths, with women being referred too late, to an inappropriate facility, and further delayed by lack of transport and poor communication between facilities. A complete referral system is needed, with all levels, from community to CEOC site, functioning as part of a whole. This should be a priority for any strategies of further improve maternal outcomes in Nepal.