Home births are rising in Nepal as fewer pregnant women visit hospitals, fuelling fears that the coronavirus pandemic could reverse years of progress on maternal health in the South Asian nation.
The government says less than half of pregnancies are now taking place in health facilities, compared with about 70 percent before coronavirus lockdowns began in March. A separate survey of health facilities across Nepal, conducted by the UN Population Fund (UNFPA) in April, found that visits by pregnant women had dropped as much as 50 percent.
Health experts say the trend is driven by fears of contracting the virus – among both mothers and health workers – as well as transportation shortages and health facility closures during lockdowns.
In June, Nirmala Joshi, 24, walked two hours to her nearest hospital in Baitadi, a mountainous district in Nepal’s remote far west, for her first prenatal check-up.
“I was scared to go to the hospital, but I had no choice: I wanted to have an ultrasound and see if the baby was doing OK,” she told The New Humanitarian by phone through an interpreter.
“My friends told me not to go, that with Covid it wasn’t safe,” said Joshi, who is four months pregnant with her first child. “They told me that they had their babies without doing checkups and all of them were fine, but my sister-in-law said I have to come.”
Health experts say convincing more women to give birth in hospitals and clinics has been crucial to reducing maternal deaths in recent years. But fears about the coronavirus, along with access problems and reduced health services, could see progress rolled back in Nepal and across the globe.
“My friends told me not to go, that with Covid it wasn’t safe.”
A study by Johns Hopkins University researchers, published in The Lancet in May, projects between 2,000 and 9,450 more maternal deaths worldwide each month from the pandemic’s indirect impacts on health and food access – an increase of between 8 percent and 38 percent over current figures. UNFPA forecasts for Nepal also project a steep rise if access to maternal health services continues to be limited.
The government says there’s not enough data to know if such predictions are materialising, though local media have reported an increase in maternal deaths since the lockdown.
But health workers and aid groups who work with pregnant women say the warning signs are clear.
Ashish Kunwar, public health manager for the local NGO Human Development and Community Services, or HDCS, worries that the pandemic could undo gains made by health services like the hospital the group runs in West Rukum, a rural district where key development indicators on health and life expectancy are already below the national average.
“We can say that mortality, infant mortality, [and] malnutrition levels were reduced by our activities, but if the situation continues we may lose the achievements because of a lack of resources or transportation,” Kunwar said. “We are aware of that – let’s see what we can do.”
Stranded during lockdowns
In March, Nepal ordered all businesses to shut and most transportation, including private vehicles and public buses, to stay off the road. Lockdown measures have been extended until at least 22 July, as Nepal struggles with a sharply rising COVID-19 caseload that has now reached more than 15,000 infections in a nation of 29 million people.
The restrictions were partially relaxed in June, allowing for some traffic to return and smaller businesses to re-open, though accessing health facilities is still a challenge.
Nepal’s Ministry of Health and Population initially ordered hospitals in Kathmandu, the capital, to close out-patient departments in March in order to prioritise COVID-19 treatment. It reversed course a week later, but not all facilities re-opened, and some are only offering partial services. A parliamentary committee and Nepal’s Supreme Court have since ordered that basic services, including for maternal health, be available in all health facilities, but lack of transport and the fear of infections continue to discourage some pregnant women.
Karuna Parajuli, 29 and into her second trimester, has had to make more trips to a Kathmandu hospital than she planned due to unexpected bleeding. She counts herself lucky: her husband is usually able to drive her by motorcycle through police checkpoints. But she has been stranded without transportation before.
“I couldn’t find a taxi and ambulances aren’t considered safe because they might have carried an infected person,” she said. “I finally had to beg a relative to take me in his vehicle.”
Though some official lockdown measures have eased, restrictions can be frequently re-imposed in rural districts like West Rukum, Kunwar said, forcing pregnant women to walk an hour on average to reach the nearest health centre.
“There are lots of local governments in the district, and local governments make their own rules,” he said. “If they discover a case of COVID-19, they’ll just seal off the area and stop all transportation.”
Healthcare workers are also anxious about their safety. HDCS’s community health volunteers, for example, are scared of going to villages: “Almost all of them have mobile phones, so they are trying to contact pregnant women, but it’s difficult,” Kunwar said.
“I couldn’t find a taxi and ambulances aren’t considered safe because they might have carried an infected person. I finally had to beg a relative to take me in his vehicle.”
The UNFPA survey of health facilities, which found a drop in pregnant women using services, also reflected these worries.
“Health workers themselves were afraid and not well equipped to handle this new context and new working environment,” said Lubna Baqi, the UNFPA country representative in Nepal. “There was a lot of nervousness about how to protect yourself in this environment… one of the things they said was that their own families were very scared of them.”
Like many countries, Nepal faces a severe lack of resources to deal with the pandemic. According to a June report by the Nepal Health Research Council, a government institution, only one third of clinics and hospitals designated for COVID-19 treatment have personal protective equipment that meets health ministry guidelines; only 60 percent have trained their workers to care for infected patients.
Planning for the long haul
Nepal has made substantial progress on maternal health in recent years, shrinking its maternal mortality ratio – a measurement of the proportion of women who die during or shortly after their pregnancies – by more than half between 1996 and 2016.
A model developed by the UNFPA estimates that the pandemic could double or triple maternal deaths in Nepal by next year, as fewer women use key services that have driven gains until now: having skilled healthcare providers assist in births, delivering in health facilities, or accessing contraception. There are currently about 1,200 maternal deaths each year in Nepal, according to government statistics.
Nepal’s health ministry says it’s too soon to know if coronavirus lockdowns are already driving a surge in maternal deaths. But early indications suggest the coronavirus is having knock-on effects across the health sector.
“Informally we can say that there might be more deaths due to the lockdown,” said Mahendra Shrestha, a spokesperson for Nepal’s health ministry. “If you see the statistics, all deaths are increasing: non-communicable disease deaths related to kidney disease, heart disease, and cancer. Another example is suicide. Suicide deaths have increased 25 percent over the same three months last year.”
Healthcare providers and aid agencies are planning for different scenarios. The pandemic is forcing groups normally focused on development programmes to consider strategies more common in emergency aid response – pre-positioning medicine and supplies, for example.
“We don’t expect that extreme environment where we are setting up medical camps” because facilities are unable to provide services, said the UNFPA’s Baqi. “But in a sense we also need to be ready for that.”
“It’s a little bit scary,” she added. “It’s hard to tell what the impact of the epidemic will be because we don’t even know the shape it’s going to take… If we give ourselves a year or 18 months I’m not so convinced that we’ll get back to exactly where we were before the Covid crisis started, and it may take much longer.”