By Dr. Nirakar Man Shrestha MBBS: MD(Psychiatry, AIIMS); FCPS; DAB (London) Chief Specialist

1. Initiatives taken in Nepal to reduce the Maternal Mortality Ratio By Dr. Nirakar Man Shrestha MBBS: MD(Psychiatry, AIIMS); FCPS; DAB (London) Chief Specialist Ministry of Health and Population Kathmandu, Nepal Tel: 977-1-4262489, Fax: 977-1-4262896/489, Email: nirakar963@hotmail.com Paper prepared for Regional Policy Dialogue Women’s Health and Rights Advocacy Partnership 27-28 July, 2005, Bangkok

2. Definition of Reproductive Health: • “A state of complete physical, mental and social well-being and non merely the absence of disease or infirmity, in all matters relating to the reproductive system and to its functions and processes.” (WHO, adopted by International Conference on Population and Development held in Cairo in 1994 and endorsed by the UN Gen. Assembly in the resolution 49/128) • Therefore, the Reproductive Health covers a life-spam perspective. • Multisectoral and multidisciplinary approach to address the issues of Reproductive Health.

3. Maternal Morbidity • Direct Obstetric Morbidity resulting from pregnancy during the antenatal, natal and postnatal periods. • Indirect Obstetric Morbidity resulting from conditions and diseases like anaemia, heart disease, tuberculosis etc. which are aggravated by pregnancy. • Psychological Obstetric Morbidity resulting from mental health problems related to pregnancy and childbirth, such as post-partum psychosis, post-partum depression, exacerbation of pre-existing mental health problems etc. • Social Obstetric Morbidity resulting from social factors related to pregnancy and childbirth, such as female foeticide, discrimination against female baby, hard physical work even during full-term pregnancy and soon after childbirth etc.

4. Regional Reproductive Health Strategy for South East Asia Region (SEAR) • As a follow-up to ICPD in Cairo in 1994, the Regional Reproductive Health Strategy for SEAR was developed in 1996 with the involvement of member countries, relevant UN agencies and NGOs. • This Regional Strategy defined an essential package of priority reproductive health interventions and these are: i. Safe Motherhood, including the care of the newborn, ii. Family Planning, iii. Prevention and management of complications of abortion, iv. RTI/STD/HIV/Infertility, and v. Adolescent Reproductive Health

5. Main Challenges in the area of Reproductive Health in the SEAR • Problem of continuing population explosion, • Unsafe abortion • High Maternal Mortality and Morbidity • High Infant Mortality, including Perinatal and Neonatal Mortality, and • Sexually transmitted infections.

6. Definitions of frequently used Terms in Reproductive Health • Infant Mortality Rate (IMR): The number of deaths under one year of age per 1000 live births. • Low birth weight: Birth weight less than 2500 gms. • Maternal Death: Death of a woman while pregnant, during childbirth or within 42 days of termination of the pregnancy, from any cause related to or aggravated by pregnancy or its management, but not from accident or incidental causes. • Maternal Mortality Ratio: The number of maternal deaths per 100,000 live births, may also be expressed per 10,000 or 1000 live births.

7. Definitions of frequently used Terms in Reproductive Health (contd…) • Perinatal Period: Period from 22 completed weeks (154 days) of gestation until seven completed days after birth. • Neonatal Period: First 28 days after birth. • Early Neonatal Period: First 7 days after delivery. • Percentage of deliveries covered: The annual number of deliveries attended by trained personnel per 100 livebirths in the same year.

8. Present Scenario of MMR and MMR Related Issues • Adolescents & youths (10-24 yrs of age) comprise of 32.5% population (CBS, 1995) • 40% of adolescent girls and 11% of adolescent boys are married (NDHS, 2001) • 25% of the married adolescent girls are either pregnant or already a mother of their first child (NFHS, 1996) • Rates of adolescents pregnancy and childbearing vary inversely with their level of education • At least 42% of Nepal’s population are functionally illiterate (UNDP, 2000) • MMR was 850 in 1988, 539 in 1995/96 and 415 in 2001/02

9. Present Scenario of MMR and MMR Related Issues (contd…) • The reasons for high MMR are as follows: – Illiteracy and lack of education especially among the rural adolescent girls. – Lack of proper school education on sexual and reproductive health because of many cultural and other factors – Premature marriage, premature pregnancy and premature motherhood (3 Ps) – Low use of family planning measures among married adolescent girls (12%) – A high proportion of malnutrition and anaemia among married adolescent girls – Inadequate coverage of family planning and other services related to sex and reproductivehealth, especially among the rural poor and in the remote areas.

10. Present Scenario of MMR and MMR Related Issues (contd…) • Proportion of all births assisted by trained health workers was (Institutional and Home) 3% in 1994 and 18% in 2003/04 (DOHS) • Antenatal Service received was 21% in 1996/97, 66% in 2003/04 but the ANC4 was only 43.6% (DOHS) • Reasons given by women who did not have any antenatal care visits during their last pregnancy were: No need perceived 34% Not part of local tradition 31% Not aware of the service 23% Too far to health facility 11% No money for visits 5% No time for visits 2% Family does not allow 1% Don’t know / missing 2% (NMIS, 1997)

11. Present Scenario of MMR and MMR Related Issues (contd…) • 90% of delivery takes place at home and only 10% takes place at institutions. But in the Kathmandu Valley, it is just the reverse. (Awareness, education, the 4 delays, female empowerment etc.) • Data from Patan Hospital has shown that Neonatal Deaths is directly proportional to Low Birth Weight (LBW) – with birth weight less than 1000g, the mortality was 416/1000 livebirths – with birth weight between 1001-1500g, the mortality was 254.5 – with birth weight between 1501-2000g, the mortality was 50 – with birth weight between 2001-2500g, the mortality was only 4 • 20% of maternal deaths in the health facilities are due to complications of abortion (HMG/UNICEF 2000) • Studies in 6 major hospitals have shown that 20% to 40% of all obstetric and gynaecological admissions are abortion-related. (CREPHA, 1998 and 1999)

12. Present Scenario of MMR and MMR Related Issues (contd…) • TFR has significantly declined from 6.09 in 1976 to 4.6 in 1996 (NFHS) and it has further declined to 3.6% (NLSS) • Percentage of deliveries covered was 7% in 1990/91, 11 in 1995/96, 13 in 2001/02 and 16 in 2003/04 • CPR has increased from 37.4% in 2001/02 to 40.2% in 2003/04 • Iron deficiency anaemia affects 75% of all pregnant women (MOH/UNICEF/WHO 1998)