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.
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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.