Scenario of the Country
Nepal is a landlocked country nestled in the foothills of the Himalayas between India and China. It covers 147,181 square kilometres of the world with a population of 23.4 million, according to the 2001 census. It is a country of geographic and cultural wonders, including the Himalayan peaks, ancient temples and colourful marketplaces. Ecologically, Nepal is divided into three distinct regions: mountains (35.2%), hills (42%), and terai or plains (23%). Nepal is predominantly rural, with only 14% of the population living in urban areas. The majority of the population resides in the terai (49%), the hills (4%) or in the mountains (6%). Transportation is limited in the mountains and hills because of the steep terrain, but generally is more developed in the plains of the terai. Its per capita income is USD $270 and the vast majority of people are subsistence farmers. Its mountains, lack of infrastructure and landlocked status pose extreme barriers to the development and delivery of health care services.
Women’s Health Status and Services
From 1996–2006, Maoist rebels fought a civil war against the Nepal government, a democracy with a House of Representatives. As a result, the overall health situation of the country is poorer than it should be. For instance, availability of essential health care services is 78.8% and life expectancy is 60 years. As in other developing countries, diseases of pregnant women and children, infections and malnutrition account for two-thirds of Nepal's illnesses.
Women in Nepal face discrimination and marginalisation in the family, society and state. This is because of the low status of women in the society. As a result, in a country where the health system is already poor, the level of women's health and education is particularly low. To compound the problem, many districts of Nepal are remote, making access to health services and information very limited.
Reproductive and maternal health is of particular concern among Nepali women. In Nepal, the key role of a woman is to bear children, particularly sons. In fact, early and excessive childbearing weakens women, many of whom die or are chronically disabled from complications of pregnancy. It is not uncommon for Nepali women to experience a prolapsed uterus following birth. This is often due to recommencing, too soon, the expected workload, which is demanding and strenuous. Often, the prolapse remains untreated and women continue their remaining reproductive life miserable due to pain and suffering.
Pregnancy is taken as a natural process and God's gift, for which any medical care is regarded as unnecessary. As a result, a majority of Nepalese women have been suffering from the aforementioned problems and complications related to childbirth. Because their overall health is poor, they have very little opportunity for exercising their reproductive and human rights. The majority of Nepalese women have no pregnancy-related contact with modern health services and maternity services in Nepal are very poor, underused and of poor quality.
According to the Nepal Demographic Health Survey (NDHS) 2006, 44% of women receive antenatal care from skilled birth attendants (SBAs), that is, a doctor or nurse-midwife; only 29% of pregnant women make antenatal care visits during their pregnancy; and less than 19% of births take place with the assistance of SBAs in a health facility, whereas 81% take place at home. Most of these homebirths are assisted by family members, neighbors, or traditional birth attendants who may be trained or untrained; or the woman may be on her own. A large proportion of maternal and neonatal deaths occur during the 24 hours following delivery. In addition, the first two days following delivery are critical for monitoring complications arising from the delivery. However, only one in five (20%) women receive postnatal care within four hours of delivery; slightly more than one in four (27%) receive care within the first 24 hours; and four percent are seen within one or two days following delivery. Each day in Nepal, 12 mothers and 75 babies die in childbirth.
The fact that 67% of maternal deaths take place at home and a further 11% on the way to hospital, coupled with the fact that 47% of deaths are due to postpartum haemorrhage, strengthens the case for skilled attendants both in the community and in accessible institutions (Pathak et al. 1998). Most of the mothers die of severe bleeding, a complication that can be treated even in basic health centers. The maternal mortality ratio (MMR), an indicator of the overall health of a population, stands at 281 deaths per 100,000 births in Nepal (NDHS, 2006). This is among the highest in the world. In comparison, the MMR is 90 in Sri Lanka and just eight per 100,000 in the US, according to the World Health Organization. Similarly, the perinatal mortality rate in Nepal is also one of the highest in the world (75 per 1000 live births). In Nepal, one woman dies every four hours from complications related to pregnancy and childbirth. The presence of a midwife could save many of them. Having a skilled professional at birth protects the life of the mother and the child by recognizing problems early, when the situation can still be controlled, and by intervening quickly.
In the 1990s, Nepal invested in two types of health workers to provide maternal/child health services and obstetric first aid at the village level: Maternal and Child Health Workers (MCHW) and Auxiliary Nurse Midwives (ANM). Neither category of worker has successfully functioned as a skilled birth attendant due to a number of factors. These include inadequate length of the midwifery component of the training; lack of competency-based training; lack of adequate clinical training and experience; professional and social isolation at post; and lack of support from the health system to enable MCHWs and ANMs to provide quality emergency obstetric and neonatal care, especially during life-threatening complications.
Since less than 19% of births take place with the assistance of an SBA, Nepal has a challenge in achieving the Millennium Development Goals (MDG) to reduce child mortality and improve maternal health (MDG 4 and 5 respectively) by addressing factors related to various morbidities, death and disability caused by complications of pregnancy and childbirth. The targets for SBAs set for the country are: 40% of all births to be assisted by an SBA by 2005, 50% by 2010, and 60% by 2015. In order to achieve this target by 2015, a total of 4907 SBAs must be in post by 2012 (from 2395 at present) (GON 2007). This is an enormous challenge because currently, as per the internationally accepted definition, only a limited number of health workers in Nepal qualify as SBAs. Furthermore, unequal access to SBAs, depending on the area in which one lives and one’s economic status, is a barrier to achieving these MDG indicators. Fifty-one percent of deliveries in urban areas are attended by a SBA, compared to 14% of births in rural areas (NDHS 2006). Against such a backdrop is a need to produce skilled birth attendants who can proficiently deal with these national maternal and child health issues.
Midwifery Practice in Nepal
At present, midwifery is neither an independent profession in Nepal, nor exist a separate cadre of midwives. Maternal and child health workers (MCHW) with three-month basic training in the clinical settings after class 8 passed mainly focusing on maternal and child health, and Auxiliary Nurse-Midwives (ANM) with 18-months of programme after grade 10th are the only midwifery care provider in the community. These workforces have limited educational background, limited midwifery training and lack of logistics support from the health system.
There is no legislation and no recognition of midwives. However, the Government of Nepal has recognized the need of producing professional midwives in the country in improving Maternal and Newborn health. It is mentioned in the National Skilled Birth Attendants Policy Long term (Pre-service) Measures (GON 2006).
Midwifery Education in Nepal
Midwifery education is integrated in the nursing programmes like in Bhutan, DPR Korea, India, and Thailand. There is no separate programme in midwifery. The entry requirement for both 36 months direct-entry programme of diploma level nursing, Proficiency Certificate Level of Nursing (PCLN) and 18 months direct-entry programme, Auxillary Nurse-Midwife is 10 grade passed and the number of normal deliveries required to be conducted during their study period varies from 10 cases depending up on the education institutions.
Based on the National Policy on Skilled Birth Attendants 2006 mid-term (pre-service) measures 27 core competencies of skilled birth attendants has been incorporated in PCLN programme and trained master of trainers and student assessment tools for clinical practice has been revised accordingly. In the long-term (pre-service) measures it has envisioned that direct-entry professional midwifery programme to produce a new cadre of professional midwife as a crucial human resource for safe motherhood, providing service and leadership in midwifery for the country.
According to the World Health Organization 2007 report of the first meeting of the South-East Asia Nursing and Midwifery Educational Institutions Network it was concluded that the teaching on midwifery in almost all nursing schools is very weak in Nepal. Therefore, there is an urgent need to review and revise midwifery course in the pre-service nursing curriculum to include core competencies of midwives or develop separate midwifery curriculum, build capacity of teachers in midwifery and teaching, build equipped midwifery laboratory, provide opportunity for students to practice their role in ANC, normal delivery, post-partum care and newborn care as per requirements for graduation.
Why focus on establishing a Midwifery profession in Nepal?
- The 2005 World Health Report: Making Every Mother and Child Count identified midwives as the essential human resource in health systems to reach the MDGs 4 and 5.
- Midwifery is a the only healthcare profession with a fundamental focus on the care of the new mother and her infant together
- Midwives provide antenatal, intra partum and post partum care as a 'point of entry' into all levels of the health system
- Their competencies also include delivery of essential sexual and reproductive health (SRH) services allowing women to make informed choices regarding family planning, testing and treatment of sexually transmitted infections and choosing safe delivery practices.
- The midwifery competencies emphasize the importance of cultural sensitivity and require that midwives have knowledge of the cultural norms about childbearing practices of the women and communities they serve.
- Historically midwives have played a pivotal role in reducing maternal and neonatal death and disabilities both in developed and developing countries helping to ensure that health services reach those in greatest need, the poor and hard to reach communities. For instance, Sri Lanka, Malaysia, Thailand, Cuba and Sweden.
- According to the National Demographic Health and Survey 2006:
- Maternal, perinatal and neonatal mortality rates remain very high 281 per 100,000 live birth, 45 per 1,000 and 33 per 1,000 respectively.
- Majority (81%) women are still giving birth at home without an assistance of skilled birth attendants (SBAs).
- Low rate of institutional deliveries (17.7%) and childbirth assisted by SBAs (18.7%). Out of this, very few deliveries are assisted by nurse-midwives (8.3%) compared to doctors (10.4%). Besides there is low rate of ANC 4th visits 29.4% including postnatal care 33%.
- Huge disparities in the utilization and accessibility of midwifery services in the regions and by residence: Hill (good), Terai (fair), and Mountain (poor); urban (Good) and rural (Poor).
- Ministry of Health and Population, UN agencies, donors and stakeholders recognized the need to develop separate cadre of professional midwives as a crucial human resource for safe motherhood, providing service and leadership in midwifery for the country (GoN 2006).
In March 2010 there was a South Asia Midwifery Strategic Planning Workshop, jointly organized by UNFPA and ICM in Dhaka, Bangladesh. It was organized as a preparatory programme to launch the International Confederation of Midwives (ICM) / United Nations Population Fund (UNFPA) Investing in Midwives Programme in Asia 2010. It was the first meeting of its kind in South Asia and addressed the nurse-midwife multipurpose worker issue within national plans in the region. The strategic planning workshop aimed at identifying existing gaps and challenges in the areas of Midwifery Education, Association and Regulation and developing country and regional level strategies for addressing these by involving all relevant partners and stake holders.
A Midwifery Service Framework was also developed, identifying at what level in the health care system where professional midwives will have most input and influence.
Government of Nepal. 2007. National In-service Training Strategy for Skilled Birth Attendants 2006–2012, National Health Training Centre, Department of Health Services, Ministry of Health and Population, Kathmandu, Nepal.
____ 2006. Skilled Birth Attendants Policy, Family Health Division, Department of Health Services, Ministry of Health and Population, Kathmandu, Nepal.
Nepal Ministry of Health and Population, New ERA, and Macro International Inc. 2007. Nepal Demographic and Health Survey 2006.
Pathak L.K., et al. 1998. Maternal mortality and morbidity study. Family Health Division, Department of Health Services, Ministry of Health and Population, Kathmandu, Nepal.
World Health Organization. 2007. South-East Asia Nursing and Midwifery Educational Institutions Network Report of the First Meeting, Chandigarh, India, 7-10 May 2007. World Health Organisation Regional Office for South-East Asia, New Delhi, India.