Policies and actions to reduce maternal mortality in Nepal: perspectives of key informants

Abstract

Nepal made impressive progress in reducing maternal mortality until 2015. Since then, progress has stagnated, coinciding with Nepal’s transition to a federation with significant devolution in health management. In this context, we conducted key informant interviews (KII) to solicit perspectives on policies responsible for the reduction in maternal mortality, reasons for the stagnation in maternal mortality, and interventions needed for a faster decline in maternal mortality. We conducted 36 KIIs and analysed transcripts using standard framework analysis methods. The key informants identified three policies as the most important for maternal mortality reduction in Nepal: the Safe Motherhood Policy, Skilled Birth Attendant Policy, and Safe Abortion Policy. They opined that policies were adequate, but implementation was weak and ineffective, and strategies needed to be tailored to the local context. A range of health system factors, including poor quality of care, were identified by key informants as underlying the stagnation in Nepal’s maternal mortality ratio, as well as a few demand-side aspects. According to key informants, to reduce maternal deaths further Nepal needs to ensure that the current family planning, birth preparedness, financial incentives, free delivery services, abortion care, and community post-partum care programmes reach marginalised and vulnerable communities. Facilities offering comprehensive emergency obstetric care need to be accessible, and in hill and mountain areas, access could be supported by establishing maternity waiting homes. Social accountability can be strengthened through social audits, role models, and empowerment of health and management committees.

Prevalence and Factors Associated With Caesarean Delivery in Nepal: Evidence From a Nationally Representative Sample

“…A previous study in Nepal showed that CS was the second significant indication for women with a previous CS, which might explain this study’s finding [ 62 ]. Multiple studies worldwide have also reported similarly that the mothers’ age remains a significant factor in determining childbirth through CS [ 21 , 53 - 54 , 63 ]. Additionally, as discussed, published studies have reported that maternal age (35+ years) is correlated with developing obstetric complications, including death [ 19 - 20 , 32 - 33 , 40 - 45 ].…”

“…These concerns regarding rural areas were also seen in the study by Karkee et al (2021), who believed that while great strides have been made in Nepal in recent years to improve care for mothers and reduce maternal mortality, there needs to be an increase in facilities in rural areas offering comprehensive emergency obstetric care to reduce future maternal mortality, which need to be accessible. There also needs to be an increase in maternity waiting homes [ 54 ]. Sapkota et al (2021) also demonstrated the inequality of ante-natal care across the provinces in Nepal [ 55 ].…”

Basic emergency obstetric and newborn care service availability and readiness in Nepal: Analysis of the 2015 Nepal Health Facility Survey

“…Recent data from the Maternal and Perinatal Death Surveillance in Nepal indicates that most maternal deaths occur in the postpartum period and of those deaths, 48% occurred within 48 hours. Further, accessing quality maternity services remains challenging in Nepal, especially for women living in the rural mountainous and hill regions [12].…”

Utilisation of quality antenatal, delivery and postnatal care services in Nepal: An analysis of Service Provision Assessment

“…This underscores the need for building HF capacity through system inputs, including trained health workers, equipment, medicine, supplies and protocols/guideline, infrastructure. Health system readiness/inputs are hindered by several supply-side barriers, including poor health system readiness and system governance, lack of health workforce accountability [ 68 , 69 ], including lack of adequate trained staff [ 70 ]. Therefore, program and policy efforts should focus on improved management and health governance systems for better HF capacity for quality MNH services.…”