Safe motherhood in Nepal has some way to go

In 1997 maternal mortality rates in Nepal were amongst the highest in South Asia. The Nepalese government and the UK Department for International Development set up the Nepal Safer Motherhood Project in order to improve emergency care for women during pregnancy and labour. How successful has this project been in achieving its goals?

The Nepal Safer MotherhoodProject, managed by Options Consultancy Services, assessed the success of theproject which project took place between 1997 and 2004, covering 9 districtsand 15 percent of the Nepalese population.

In Nepal challenging terrainoften means the cost of transport is the most expensive part of a hospitalbirth. From the plains it can take almost three hours to get to hospital, whilein the mountain districts it takes on average eight hours. Travel has becomeeven more difficult in the past ten years because of the armed conflict. Anormal home delivery costs, on average, US$9 while in hospital it costs $73. Acaesarean delivery in hospital costs twice as much and equates to a poorfamily’s income for six months.

The study found that families hadto borrow money or sell their possessions in order to pay for a hospitaldelivery and fee exemptions for the poorest families were not being applied. Bythe end of the project:

• Fourteenpercent of women received the emergency care they needed in the districts wherethe project was operating. Before the project this figure was below fivepercent.
• Nursesand paramedics had been successfully trained to provide anaesthesia and inthree districts nurses managed seventy percent of emergency procedures.
• Despiteefforts to increase awareness about danger signs in pregnancy, nearly a quarterof women sampled first bought drugs or attended private clinics beforeattending the hospital.
• Emergencyfunds set up by the project were effective for many members of the community.However, the poorest people could not always access them because they were notconsidered creditworthy.
• Themajority of women using the hospitals were from the higher castes.

There is still a long way to goto improve maternal services in Nepal. Despite better infrastructure andequipment, there are still serious shortages of skilled professionals. In orderto reduce maternal mortality the study recommends that:

• therole of nurses is expanded to meet skill requirements for basic obstetric care
• Nepal’snew Health Sector Programme improves the public sector referral system
• thepoorest families are subsidised by central government
• womenare made more aware of their health care rights
• governmentpolicy-making utilises both local knowledge and the experiences of othercountries who have implemented similar programmes.

In countries with very highmaternal mortality, focussing solely on the health service is not enough.Class, sex and ethnicity all play a part in determining whether someone willreceive the health care they need. Women in Nepal are undervalued and havelittle power, while women from lower castes and ethnic groups are even moremarginalized.