Transcript Measuring Maternal Mortality Rate in Nepal: Initiatives and Efforts Prepared By Nava Raj Lamsal Statistics Officer Central Bureau of Statistics Branch Statistics Office, Nuwakot Nepal ESA/STAT/AC.219/18

Measuring Maternal Mortality
Rate in Nepal:
Initiatives and Efforts
Prepared By
Nava Raj Lamsal
Statistics Officer
Central Bureau of Statistics
Branch Statistics Office, Nuwakot
Nepal
ESA/STAT/AC.219/18
Introduction
 Nepal is a land-locked country nestled
in the foothills of the Himalayas.
Situated in the northern hemisphere,
known as land of Mt. Everest and the
birth place of Lord Buddha, Nepal is a
tiny country. Though Nepal occupies
only 0.03% and 0.3% of total land
area of the world and Asia
respectively, the country has an
extreme topography and climate.
Contd.

Topographically, Nepal is divided into three distinct
ecological zones: These are the mountain, hill and terai
(plains). The mountain zone, ranges in the altitude from
4,877 meters to 8,848 meters above sea level and covers a
land area of 51,817 square kilometers and only about 7
percent of the total population lives here. In contrast, the
hill ecological zone, which ranges in the altitude from 610
meters to 4,876 meters above the sea level, is densely
populated. About 44 percent of the total population lives in
the hill zone, this covers an area of 61,345 square
kilometers. Unlike the mountain and hill, the terai zone is
the southern part of the country can be regarded as an
extension of the relatively flat Gangetic plains of alluvial
soil. The terai consist dense forest area, national parks,
wildlife reserves, and conservation area. This area, which
covers 34,019 square kilometers, is the most fertile part of
the country and 49 percent of the population lives here.
Contd.
 According to the population Census
2001,the annual growth rate of
population is 2.25 percent and the
total population of the country in
2008 has reached about 26.9 million
of which the proportion of male and
female are almost equal. About one
third of the populations (30.8%) live
below poverty line and Ginni
Coefficient 41.4.
Contd.
 Nepal has taken a Population Census every 10 years
since 1911.The latest census of Nepal was 2001
Population and Housing Census. Maternal Mortality
Rate has been estimated after launching the program
of the Safe Motherhood. Nepal Demographic Health
Survey (NDHS) began collecting maternal mortality
data through a series of questions designed to obtain
a direct measure of maternal mortality. These
questions were included for the first time in the 1996
Nepal family Health Survey (NFHS) and again ten
years later in the 2006.
Contd.
 As regards the national statistical system of
Nepal, the present system is de facto
decentralized. Central Bureau of Statistics
(CBS) is the pivotal statistical agency within
the national statistical system and it has 33
branch statistics office throughout the
country. CBS was created in 1959 by virtue
of Statistics Act, 1958 as the sole agency
for the collection, consolidation, publication
and analysis of statistics.
The data of Maternal Mortality
 Over the past two decades, the high level of maternal
mortality in developing countries has increasingly
been recognized as an urgent public health concern.
In 1987, the Safe Motherhood Conference in Nairobi,
Kenya, drew attention to maternal mortality, and the
issue has remained on the international agenda ever
since. The Millennium Development Goal-Five (MDG5) is to improve maternal health, with the target of
reducing the 1990 maternal mortality ratio (MMR) by
three quarters, by 2015. The Government of Nepal
(GoN) is committed to achieving this goal and
developed a national Safe Motherhood Plan of Action
(SMPoA) in 1994. Since then, safe motherhood has
been a national priority for Nepal.
Contd.
 A Maternal Mortality and Morbidity
(MMM) study was conducted in Nepal
in 1998 as part of the determined
focus on maternal mortality. The
study was designed to gain a better
understanding of the causes of death
for women of reproductive age.
Contd.
 The two main sources of data
providing national level MMR
estimates are the NDHS/NFHS and
World Health organization (WHO).
Other sources of data on maternal
deaths in Nepal include surveillance
data from Mother and Infant research
Activities (MIRA) and the government
Health Management Information
System (HMIS) data.
Contd.
 The 1996 NFHS reported an MMR of 539 maternal
deaths per 100,000 lives births, with a 95 percent
confidence interval. The 2001 NDHS did not attempt
to measure maternal mortality and the 2006 NDHS
reported and MMR of 281 maternal deaths per
100,000 live births. The point estimates of MMR
suggest that maternal mortality has declined by 48
percent over the last ten years. The Government of
Nepal has
conducted the latest survey in 13 April
2008 to 13 April 2009 and found that the overall MMR
for the eight districts is 229 per 100,000 live births,
ranging from 153 to 301 by district. This is consistent
with the 2006 NDHS survey data.
Contd.

Maternal mortality ratio 1987-2009
Reference Year
Ratio Per
100,000
Source
1991
515
NFHS,1991,MOH
1990-1996
539
NFHS,1996,MOH
1998
596-683
MMMS,1998,MOH
2006
281
NDHS,2006
2009
229
MMMS,2008/09,M
0HP
Plan, policy and provisions
 Safe Motherhood was identified as a priority
programme in the GoN National Health policy
1991. A National Safe Motherhood Policy was
formulated and endorsed by the Government in
1998. The policy placed emphasis on
strengthening maternity care, including family
planning services, at all levels of health care
delivery system; enhancing technical skills of
the health care providers at all levels; and
strengthening referral services for emergency
obstetric care. The major health plan and
policies are summarizing below.
Conted.
 Long Term Health Plan-I1975-1990, National Health
Policy-1991,National Safe Motherhood Plan of
Action1994-97,Long Term Health Plan-II19972017,National Safe Motherhood Policy-1998,Safe
Motherhood Plan of Action2001-2015,National Safe
Motherhood Plan2002-2017,Tenth Plan20022007,Nepal Health Sector Program Implementation
plan2004-2009, National Policy for Skilled Birth
Attendants-2006,National Safe Abortion policy2006,Safe Motherhood and Newborn Health Long
Term Plan2006-2017,Three Year Interim Plan2007-09
Conted.
 All these plan; policies and provisions are
based on the national and international
commitments committed by the Government of
Nepal such as CEDAW (articale12), CRC, ICPD
(+5, 10) PRSP, BPFA (women and health) and
MDGs(5). The Government of Nepal
implemented to provide transportation package
for the pregnancy women if she made delivery
in the health institutions. Under this provision
women can get Rs.500, Rs.1000. and Rs.1500
respectively in the teari, hill and mountain
areas.
Maternal Health Care System
 According to national guidelines maternal
services aims to help families take
appropriate decisions through health
information and counseling, to provide
basic antenatal and delivery services to all
present women and to ensure referral and
adequate obstetric care to high-risk
mothers and obstetric emergencies. The
maternal health care system in Nepal
operates at various levels;
Contd.








Household
Community (About 48,000 FCHV)
Sub health Post
Health Post
Primary Health Care Center
District Hospitals
Zonal and regional hospitals
Central level hospital
Barrier to Maternal Health Care
 Despite substantial inputs over a number of years
from the side of the Nepal government and its safe
motherhood partners, significant barriers still exist for
women needing to seek maternal health care, on both
supply and demand side.
 Demand Side Barriers-Lack of understanding,
Culture of Silence, Family and Social Restriction,
Tradition Beliefs and Practices, Too Shy or Ashamed to
Seek Care ,Distance to Health Facilities and Lack of
Transport, Cost of Health Care,
 Supply Side Barriers-Availability of Services and
Referral, Quality of Facilities, Availability of Drugs and
Suppliers, Availability and Ability of staff, Staff
Attitude
Methods to estimate Maternal
Mortality Rate

The maternal mortality ratio (MMR), which is obtained by
dividing the age-standardized maternal mortality rate by
the age-standardized general fertility rate, is often
considered a more useful measure of maternal mortality
because it measures the obstetric risk associated with each
live birth. The most recent NDHS, 2006 uses a variant of
the sisterhood approach called the direct sisterhood
method. The sisterhood method obtains information by
interviewing a representative sample of respondents about
the survival of all of their adult sisters to overcome sample
size problems. The direct approach relies on fewer
assumptions and collects more information than the original
indirect method, but requires larger sample sizes and the
analysis is more complicated. The sisterhood method is a
time of death measure rather than cause of death measure
and hence identifies pregnancy related deaths rather than
maternal deaths.
Contd.
 In 2000 WHO applied the observed
Proportions Maternal among Deaths of
Females of Reproductive Age (PMDF) from
the sisterhood data to the number of nonHIV female deaths aged 15to49 estimated
to calculate maternal deaths. The MMR was
then obtained by dividing total maternal
deaths by the estimated of live births as
reported in the United Nations
Demographic Yearbook.
Contd.
The recent study 2008-2009 followed the
following methodology, which covered both
qualitative and quantitative aspects.
 A community surveillance system
 Maternal Death reviews
 Rapid facility and staff competency
assessments
 Emergency Obstetric Care (EOC)
monitoring
 Using Qualitative components, group
discussions and interviews
Conclusion
 The information is essential for informed policy
decisions, planning, monitoring and evaluation of
programs on health in general and reproductive health
in particular at both the national and regional levels. A
long –term objective of the census and survey is to
strengthen the technical capacity of government
organizations to plan, conduct, process and analyze
data from complex national population and health
surveys. In Nepal, Series of Population census has
been conducted since 1911 and 11th census is going
to be conducted in the 2011 by the Central Bureau of
Statistics.
Contd.
 In addition to the population census, different surveys
also conducted for the purpose to measure demographic
features. The latest NDHS had been done in the 2006,
data from this third survey, allow for comparisons of
information database on demographic and health
variables. The principle objective of this survey was to
provide reliable data on fertility, child mortality,
nutritional status, maternal mortality etc. Three
questionnaires were administered: the household
questionnaire, the women's questionnaire, and the men's
questionnaire. The women's questionnaire was used to
collect information from all women age 15-49 which is
related to the maternal mortality ratio. Pregnancy
histories were taken from all eligible women aged 15-49
years in the households sampled for the 2006 NDHS.
Contd.
 Since the national safe motherhood
programme was launched in 1997 and
designated a (P1) priority programme,
substantial financial and other resources
have been invested in the effort to reduce
the high national MMR. The 2006 NDHS
indicated encouraging success, with much
reduced MMR; however, a further analysis
indicates this is not solely the result of
improved care, as evidence shows modest
progress in this respect, at best
Contd.
 Finally, the government of Nepal has made lots of
commitment such as CEDAW, BPFA and MDGs etc.
nationally and internationally to empower the women
and children. By using committed instruments plan,
policy and program has been prepared. Under these
programs reduction of maternal mortality is one of the
most important national agenda. To make success
national agenda without proper information is
impossible. For this purpose, Government of Nepal has
initiated to measure MMR through census, surveys and
vital registration systems. Central Bureau of Statistics is
one of the government agencies to collect, compile,
analyses and dissemination of the data. It has planned
to estimate MMR in the upcoming census 2011 which is
1st time in Nepal.
THANK YOU.