Maternal Morbidity Study
Over the last 20 years, the Government of Nepal has been working to reduce the number of women who die during pregnancy & childbirth. Following significant efforts, maternal mortality has reduced from 539 to 229 per 100,000 live births between 1998 and 2008. We initiated a Maternal Mortality and Morbidity Study (MMMS) in 2008 to investigate the reasons behind these changes. The study explored and identified factors that contributed and the experiences in different regions of the country. It aimed to tie in with efforts to achieve Millennium Development Goal 5, to reduce maternal mortality ratio (MMR) by three quarters between 1990 and 2015. The study has informed policy makers and programme managers, helping to strengthen and refocus the national effort to avert maternal deaths, ncluding the launch of a major national, multi-sectoral campaign against gender-based violence (GBV).
We added three new components to the study, to ensure more robust findings. These included:
- A community surveillance system to identify all live births and deaths during the study period. Pregnancy-related deaths were verified from local records and verbal autopsies.
- Maternal Death Reviews (MDR) at all hospitals in the study districts, to better understand the factors that contributed to maternal deaths in facilities.
- Rapid assessments in 43 selected facilities (public, private and NGO) to examine the capacity of facilities, availability of staff, quality of services and the knowledge, competencies and practices of providers.
- Monitoring emergency obstetric care using a maternity register to track UN process indicators on uptake and efficacy of treatment, and levels of maternal morbidities.
- In-depth interviews and focus group discussions to gather information on care seeking behaviour during pregnancy, delivery and the postpartum period; socio-cultural practices relating to pregnancy and childbirth; quality of care experienced; barriers and challenges in providing and seeking care; and changes over the past ten years.
The MMMS established suicide as a leading cause of death among women of reproductive age, indicating that it is a major hidden public health problem. It brought the nature, scale and impact of suicide among women of reproductive age to government and donor attentions.
As a result, the UK government and United Nations Family Planning Association (UNFPA) jointly funded a review of the evidence on suicide among young women in Nepal, in 2010.
UK Aid, UNFPA and others helped launch the government’s major campaign against gender-based violence. This multisectoral initiative led to the establishment of 21 One Stop Crisis Management Centres (OCMCs) across the country, providing health and counselling services, access to legal advice, safe houses and vocational skills training for young women experiencing domestic violence.
- The MMMS identified significant improvements over a 10 year period; the MMR reduced from 539 per 100,000 live births in 1998 to 229 per 100,000 live births in 2008.
- Delays at health facilities were a major factor contributing to maternal deaths, which later became a key area of focus.
- In 1998, 21% of maternal deaths occurred in a facility and 67% at home. By 2008, 41% of deaths were occurring at facilities, indicating an increase in the use of facility services, albeit often too late. In this regard, it was reported that most women with complications arrived at the facility in a critical condition.
- Learning from our findings, the National Health Sector Strategy 2015-20 emphasises a multi-sectoral approach to address and monitor the suicide rate.
- Guided by the MMMS, the Ministry of Health established a Maternal and Perinatal Death Surveillance and Response System in five districts involving around 50 hospitals. The MoH aims to review and respond to all institutional maternal deaths in the country by 2020. Identifying and acting in response to the causes of maternal deaths will lead to significant improvements in quality of care for women during childbirth.
The MMMS catalysed the government’s campaign against GBV and subsequent establishment of OCMCs across the country.
Maternal and Perinatal Death Surveillance and Response System established in 5 districts involving 50 hospitals.
The MoH aims to review and respond to all maternal deaths occurring in health facilities by 2020.
Lack of blood, a major contributor to maternal deaths, is being tackled with a revised Safe Blood Policy.