Making childbirth safer for mothers in Nepal

More than 90 percent of women in rural Nepal deliver at home alone or with relatives. Illiteracy, preference for the home environment, geography, poor quality services and ongoing conflict all limit their access to skilled obstetric care. What impact does affordability have on care seeking?

Thematernal mortality ratio in Nepal is among the highest in Asia, at around 539per 100,000 live births. Skilled attendance at birth would help to reduce thisto the target figure of 300. But how much would this cost? Research involvingthe London School of Hygiene and Tropical Medicine, UK, measured costs andwillingness-to-pay for three levels of delivery care services:

• thecurrent pattern of service use
• alldeliveries in a health facility
• skilled attendance at home.

Householdsurveys covering 720 women across eight districts showed that:

• Theaverage cost to a household of a home delivery ranges from US$5.43 with afriend or relative attending, through US$10.05 with a trained or untrained traditionalbirth attendant, to US$11.63 with a health worker.
• Ata health facility, the average fee for a normal delivery is US$8.97, withadditional charges, companion time and transport costs taking it above US$70.
• Forthe poorest 144 people surveyed, these costs represent three months ofhousehold income, compared with just over one month for the wealthierhouseholds. More than one in five women delivering at home say cost is the mainbarrier to delivery at a facility.
• Inmountainous districts, women spend an average of 8.3 hours reaching anobstetric care facility.
• Onaverage, women are willing to pay up to US$9.70 for delivery at home with atrained attendant, or US$64.67 for delivery at a comprehensive essentialobstetric care facility.
• Theannual per capita cost of current practices is US$0.60. Universal institutionaldelivery would cost US$3.15 per capita, while skilled attendance at home andearly referrals from remote areas would cost US$1.55.

Governmentsmust consider short and longer term costs of strategies to increase thecoverage of skilled attendance at delivery and ensure that these can befinanced from domestic or external sources. Nepal’s annual public health budgetis around US$5 per head so cost sharing between households and government isinevitable. The researchers propose a combination of improved financing fordemand-side costs and early referral in remote areas plus an increase in thenumber of comprehensive essential obstetric care facilities. To improveaccessibility and equity of service provision, they also recommend:

• encouragingor requiring public facilities to develop and publicise standard charges forservices
• makinghome delivery safer through public funding of safe delivery kits and greaternumbers of attendants with midwifery training
• improvingmechanisms to direct funds to women in greatest need
• providingbetter finance for payment exemptions in public facilities for the mostvulnerable
• offering public funding for transport for low incomehouseholds.