Focus on maternal mortality

Dinanath, a Nepalese farmer, was struck by tragedy when he lost his wife following the birth of their child a few months ago. She survived prolonged labour and the eventual delivery of their baby in their home village of Karma, 200 km south west of the Nepalese capital, Kathmandu. There was no trained midwife in attendance to assist the 35-year-old woman. When she started bleeding following the delivery, Dinanath tried to get her to the nearest health centre at Bahadurganj, about 8 km from his village. As buses rarely travel through the area, the ox-cart is the only means of transport and the journey takes more than two hours. Dinanath was desperate to save his wife and drove the ox as hard as he could in his attempt to get medical help for his wife. His efforts were in vain and she died on the journey. In the village of Sisuwa, only a few kilometres from Karma, another poor farmer, Radhe, lost his 18-year-old wife in the same way. This is the harsh reality of childbirth for many women in the district, who die from complications because of the lack of health care personnel or medical centres, according to NGO and government health workers. The nearest hospitals staffed with trained midwives are up to 70 km from their villages. They either have to travel all the way to Butwal, the main city in southwest Nepal, or cross the border to neighbouring India. The nearest Indian hospital is in Siddharthanagar, at least 40 km away. The roads are beset with frequent politically-motivated strikes and numerous roadblocks manned by Maoist insurgents, who have been waging a nine year campaign in Nepal. Many women make agonising journeys over long distances seeking help. There have been several reported incidents of pregnant women dying on the road because transport problems have preventing them from reaching hospital in time. “The conflict has added more pressure to the maternal related problems,” Aruna Upreti, a reproductive health worker, told IRIN. The actions of Maoist rebels have escalated in recent years and in response the government has imposed curfews in many areas. Transport has been hit with restrictions on the movement of vehicles after dark and even travel on dirt roads between villages. Trenches have been dug across roads on several routes to prevent the movement of vehicles. Ambushes on the main east-west highway have also deterred buses from travel mounting a regular service and in these areas cases of pre and post-natal mortality are reported to have been high. Despite these problems, health workers agree that the difficulties created by conflict are insignificant when compared with the impact of such issues as poor medical facilities, practices that endanger the health of pregnant women and simple government negligence. THE SCALE OF THE PROBLEM According to Ministry of Health estimates, pregnancy-related complications kill over 4,500 women every year in Nepal. Most of the deaths occur in rural areas, where access to health services and health personnel is severely limited. Women constitute slightly more than half of the country's total population of 25.7 million. A 1997 government report estimated the maternal mortality ratio to be 530 per 100,000 births. The Human Development Report for 2004 by the United Nations Development Programme (UNDP) estimates the figure to be substantially higher at 740 per 100,000 births. A third report by the Population Reference Bureau, a US-based NGO, places the figure even higher still at 830 per 100,000 births. Whatever the actual number, the reality for pregnant women in Nepal is extremely bleak. Health experts blame three main factors for the terrible mortality rate, referring to them as ‘the three D’s.’ They list them as delay in taking the decision to seek medical assistance, delay in accessing the appropriate care and the delay of care at health centres. Around 900,000 pregnancies are expected this year and statistics indicate just under 129,000 will develop life-threatening complications, according to data supplied by the national Support for Safe Motherhood Programme (SSMP) run by the government and funded by the UK Department for International Development (DFID). “I don’t see maternity mortality as a public health indicator but more as a human rights and gender discrimination issue,” Indira Shrestha from the SSMP, told IRIN in Kathmandu. HOME BIRTHS Successive governments in recent years have each failed to invest in health facilities in rural areas, according to experts. Because of this more than 89 per cent of births take place at home with the assistance of relatives, friends and untrained midwives, according to official statistics. Only eleven per cent are attended by properly trained medical staff. "It is not that Nepal does not have trained health professionals. It does. The trouble is that they tend to be clustered in Kathmandu and other major cities,” Dr Geetha Rana, a safe motherhood expert from the United Nations Children’s Fund (UNICEF) in Nepal, told IRIN. UNICEF works closely with district public health offices to improve the quality of care and treatment. In the absence of trained midwives, many women suffer from prolonged labour and complications caused by a retained placenta. According to statistics, a large number of them die from subsequent bleeding or ‘post-partum haemorrhage’ amounting to about 46 percent of maternal deaths. “Post-partum is the most dangerous period. The treatment should be taken immediately when the bleeding starts,” Swaraj Pradhan Rajbhandari from Nepal's Family Health Programme of United States Agency for International Development (USAID), told IRIN. Even small district hospitals have such medication available but the treatment must begin within two hours to be effective. REASONS FOR DELAYS The problems arise when family members in rural areas don’t take immediate action to get the woman to hospital, according to some health experts. The low value of the daughter-in-law in Nepalese culture and cash problems lead to the delay. “She will be rushed to the hospital in the last hour. By that time, it will be too late to save her,” Rajbhandari added. According to one recent report from the eastern Morang district, a woman in her fifth pregnancy and under medical supervision, suffered from internal bleeding after her uterus burst. Family members refused to donate blood when asked by the doctor. “If she dies then that is her fate,” the family members, including her husband, told the doctor. “I will feel weak if I give her my blood,” said the husband. In less than an hour, she was dead. “This is an example of how low women are valued and how they are so grossly discriminated [against],” health worker Upreti explained. She has travelled extensively in the most remote areas to treat pregnant women. “She did not die due to a lack of doctors or medicines,” said Upreti. EFFORTS TO REDUCE THE PROBLEM Although the global initiative to reduce maternal mortality and promote safe motherhood practices started in the mid 1980s, Nepal was slow to start any national initiative despite having one of the highest death rates. It was only after the Cairo conference on population and development that Nepal finally launched the national safe motherhood plan of action. International pressure following the national health survey of 1996 pushed the government of Nepal into initiating a programme of action. Nepal has a long way to go to achieve the Millennium Development Goal of achieving a 90 per cent attendance at birth by trained personnel and reducing the maternity mortality ratio to 200 per 100,000 births by 2015. “What we need most is raising awareness in the rural areas to practice safe motherhood. This is possible even in a conflict situation,” Ava Darsan Shrestha from Samanta, the secretariat of Safe Motherhood Network run by a consortium of NGOs working in 10 remote districts of Nepal, told IRIN. Samanta organised a health camp on prolapse of the uterus from November 2004 to February 2005 when about 5,500 women and girls were given free treatment. “The camp showed us that women are willing to travel any distance if services are available. When it comes to reproductive health, they will not hold back even if it means travelling to conflict zones,” Pinky Singh Rana from the network told IRIN. The Family Health Division is beginning to replicate the Sri Lankan model by initially training professional health workers in the skills needed. It plans to focus on the establishment of numerous birthing centres staffed by 6,000 midwives both in the rural countryside and in Nepal’s mountains and hills. Before 1999, front-line maternal health care providers were known as ‘maternal child health workers’ (MCHWs) of which there were over 3,000 in all. However, they are not now recognised as skilled health workers. In 1999, the government introduced a policy to upgrade MCHWs to Auxiliary Nurse Midwives (ANMs). But half of them weren’t eligible for further training as most of them hadn’t finished school. According to SSMP, over 700 trained midwives are needed in 16 mountain districts. “The government does not have to bear all the financial and logistical responsibilities. The community can deploy and the government can sponsor education,” Shrestha from SSMP said. “This is perhaps our only hope and the most practical solution,” she added.