Measuring Maternal Mortality Rate in Nepal: Initiatives and Efforts

1
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

2
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.

3
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.

4
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.

5
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.

6
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.

7
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 (MDG-5) 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.

8
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.

9
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.

10
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.

11
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,M0HP
12
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.

13
Conted.

• Long Term Health Plan-I1975-1990, National Health
  Policy-1991,National Safe Motherhood Plan of
  Action1994-97,Long Term Health Plan-II1997-2017,Na
  tional Safe Motherhood Policy-1998,Safe
  Motherhood Plan of Action2001-2015,National Safe
  Motherhood Plan2002-2017,Tenth Plan2002-2007,Nepal
  Health Sector Program Implementation
  plan2004-2009, National Policy for Skilled Birth
  Attendants-2006,National Safe Abortion
  policy-2006,Safe Motherhood and Newborn Health
  Long Term Plan2006-2017,Three Year Interim
  Plan2007-09

14
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.

15
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

16
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

17
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

18
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.

19
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 non-HIV 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.

20
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

21
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.

22
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.

23
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

24
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.