As published in the medical journal The Lancet last month, “Maternal mortality for 181 countries, 1980–2008: a systematic analysis of progress towards Millennium Development Goal 5”, researchers from the University of Washington and the University of Queensland, Australia, created a database of over 2,500 observations of maternal mortality from 1980 to 2008 to generate yearly assessments. [break]
Deaths resulting from HIV infection were included in the statistics. The study attempts to fill a crucial gap in accurate monitoring, needed to track progress on maternal mortality as well as advocate for resources and enhance policy.
Funded by the Bill and Melinda Gates Foundation, the overall global figures were found to be much lower than generally accepted. While the new study deduced that the number of maternal deaths worldwide has decreased from an estimated 526,300 in 1980 to 342,900 in 2008, the World Health Organization maintains that for 2005, this number hovers at 536,000. The wide discrepancy in results has the global maternal mortality community in endless debate about which statistical sources are the most significant. Either way, most results follow a general declining trend.
Lowest in South Asia
As revealed by the Lancet data, Nepal’s MMR has gone down from 865 in 1980 to 240 in 2008, the current lowest ratio in South Asia. While the region as a whole has seen substantial reductions of over 40% in its MMR in 2008 compared to 1980, it is also host to Afghanistan – with the highest MMR worldwide at 1,575 – and India, with the largest number of maternal deaths in any country. Other countries in the region that have seen remarkable declines between 1980 and 2008 are Bhutan (from 2,116 to 255) and Bangladesh (from 1,329 to 338).
National statistics on MMR show comparatively similar results. The first Maternal Mortality and Morbidity (MMM) study in 1998 revealed an MMR of 539 per 100,000 live births. By the last Nepal Demographic and Health Survey (NDHS) conducted in 2006, the national MMR was calculated at a much less 281. More recently, the 2009 MMM study deduced an MMR of 229. Unfortunately, the upcoming 2011 NDHS will not include an assessment of maternal mortality because it requires an expensive survey process.
Stimulating policy review
The Lancet article asserts that “although our analysis does not provide explanations for these accelerated decreases, we hope that the results will stimulate detailed policy reviews.” Indeed, in Nepal this has stimulated much discussion, with some considering it proof of successful government policies and consistent efforts to reduce maternal mortality over the past decades.
“We have been working hard to reduce the maternal mortality ratio in Nepal; therefore, the outcome was anticipated,” explains Dr. Naresh Prasad KC, Director of the Family Health Division at the Department of Health Services. These include free delivery services and transportation subsidies, stationing of doctors in remote areas to conduct c-sections and handle other birth complications, as well as antenatal and post-natal care and counseling by trained female community health workers.
Overall, the national health policy of 1991, which began a process of building sub-health posts in every village development committee (VDC) throughout the country, has contributed to improved access to health services. Recently, the Nepal Health Sector Programme Implementation Plan II (2010-2015) has plans to upgrade all the sub-health posts to health posts. More specific to maternal health, the Safe Motherhood Plan of Action (2002-2017), National Safe Motherhood and Newborn Health-long-term plan (2006-2017), and National Policy for Skilled Birth Attendants (2006) have all reflected Nepal’s commitment to the cause.
Each has sought to increase the number of deliveries assisted by a Skilled Birth Attendant (SBA), improve emergency obstetric care and administering of caesarian sections. Through the Safe Delivery Incentive Programme of 2005, cash incentives were provided to women who gave birth in a health facility and health providers who attended each delivery; and in 2009, the Aama Surakcchya Programme established free delivery care at all public health facilities.
Others, like Sharada Pandey, Senior Public Health Administrator at the Ministry of Health and Population, attribute the reduction in MMR to significant improvements in indirect causes of maternal mortality. These include successful policies to tackle micronutrient deficiencies, such as Vitamin A, iron and iodine schemes.
“When the first National Nutrition Survey was released in 1998, it was like a Bible for us.” As Dr. Oona Campbell, coordinator of the MARCH Centre for Maternal, Reproductive & Child Health at the London School of Hygiene and Tropical Medicine further explains, “one of the first studies to demonstrate the effect of Vitamin A on MMR reduction was done in Nepal,” showing reductions of up to 40%. However, these results have not been replicated elsewhere, with studies in Bangladesh and Ghana revealing no statistically significant link between the two.
Other contributing factors have been the legalization of abortion in 2002 for the first 12 weeks of pregnancy; a reduction in fertility from an average of four to three children, coupled with an increase in the use of contraceptives from 26% in 1996 to 44% in 2006; and a drop in the number of women with no education.
Still, in Dr. Campbell’s words, “Nepal is like a little puzzle.” MMR has declined in Nepal despite results that would expect the contrary. For example, significant policy initiatives to increase the number of Skilled Birth Attendants (SBA), coverage of births by SBAs remains low at 19%, according to the 2006 NDHS survey, and the number of women receiving postnatal care is only at 24%. Most Nepali women continue to deliver at home. Cesareans have tripled, but to a measly 3%. The number of women dying due to unsafe or incomplete abortions doubled between the MMM study in 1998 and the one in 2009, although this may be attributed to increased reporting. Although a climb in the use of health facilities was observed, this was mainly in the case of an emergency, with most women arriving in an already critical state.
These incongruities may be due to unreliable statistics, as is sometimes suggested in the global conversation around the recent Lancet review, but what cannot be denied is that Nepal has come a long way from 2006, when the “World Disaster Report” released by the International Federation of Red Cross and Red Crescent Societies revealed that “the maternal death toll of one woman every 90 minutes makes Nepal the deadliest place in the world to give birth, outside Afghanistan and a clutch of countries in sub-Saharan Africa.”
If nothing else, the latest Lancet analysis “suggests there is a much greater reason for optimism than has been generally perceived, and that substantial decreases in the MMR are possible over a fairly short time.”
In order to reach its target for its Millennium Development Goal 5 – to reduce the maternal mortality ratio by three quarters between 1990 and 2015 – Nepal will have to trim down to an almost 118.
But Dr. KC of the DHS is ambitious and optimistic.
“The recent review has been very encouraging for us and has made us even more committed to achieving our target for MDG 5, maybe even surpassing it to reach below the hundreds.”
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