Systemic flaws as maternal health hazards

B

eing a mother is never easy, and being a new one can be complicated. Psychiatrist Pratistha Ghimire of Nepal’s Paropakar Maternity and Women’s Hospital in Kathmandu even says that anxiety is the no. 1 symptom that she sees among the first-time mothers who consult with her.

“They are anxious about how they will take care of the newborn and related to that also, how they will adapt to their new life,” says the young doctor as she sits in her new office, a short corridor removed from the bustling hallways of the country’s largest hospital for women. “I’ve seen working mothers who are worried about how they will manage their career and their baby when they don’t have any support system.” 

She says that most of the five or six women she meets each day — apart from group sessions she holds in the wards — just need counseling on how to handle their new role as a mother. But Ghimire adds that a few have needed medical treatment, mostly for depression.

Nepal’s maternal mental health program was set up in Maternity Hospital (as the Paropakar health facility is more popularly known) in late 2024, following a government study that revealed suicide as the cause of 6% of maternal deaths in the country. 

The World Health Organization (WHO) says that 15.6% of Nepali women experience a mental health disorder (usually depression) during pregnancy and 19.8% after delivering. Those figures are higher than the global average, adds WHO.

The maternal mental health program is one of many measures that Nepal has been launching in recent years to tackle maternal and child deaths, in an effort to replicate the country’s successes in previous decades, as well as to meet the targets of the 2030 Sustainable Development Goals (SDGs), specifically Goal 3. 

Yet experts questioned about the initiatives point to other issues – among them system inefficiencies — that also need to be addressed to improve maternal and child health (MNCH) and reduce the country’s maternal mortality rate (MMR). 

“We did pick the low-hanging fruit,” says Surya Bhatta, interim co-CEO of One Heart Worldwide (OHW), an international organization that has provided maternal health services in Nepal’s remote districts since 2010. “Facility-based deliveries increased, ANC (antenatal care) visits increased.”

“Now the big challenge is quality and accountability. Delivering a high-quality health service requires an entire ecosystem that functions. Facility readiness, for one.”

“I just came from Jajarkot (district),” continues Bhatta. “I was (also) there in 2010-11 and in the nearby Dolpa district. I remember there was very limited healthcare versus what they have now: access to a beautiful facility, committed staff, very qualified people.”

“But that is not enough; the service continuity needs to be there. At one hospital we visited this time both the obstetrician and the skilled birth attendant were on leave, so cesarean sections could not be done. But that’s a vital service. You can’t just close it because two people are away,” Batta adds.

Success, then sputters

Nepal has indeed made progress on maternal health, as noted by Bhatta and in the Department of Health Services’ own annual reports. Institutional delivery rose from 64% in 2016 to 83% in 2022-23. 

In 2016, just 54% of women got cash incentives to defray travel costs to deliver in a facility; that jumped to 76% in 2022-23. And the number of new mothers who received postnatal checkups within two days climbed to 72% in 2022-23, from 57% in 2016.

In 2010, Nepal had even received a Millennium Development Goals award for its achievements in reducing its MMR, which nearly halved between 1996 and 2006: from 530 deaths per 100,000 live births to 281 per 100,000. 

Nepal’s MMR has continued to fall since, with the latest figure at 151, according to the government’s 2021 Report on Maternal Mortality. But the rate does not appear to be on track to meet the SDG Goal 3 target of 70 per 100,000 live births, with the WHO predicting an MMR of 95 for Nepal in 2030.  

Worldwide, Nepal ranks 51st among 186 countries in terms of MMR, based on 2020 estimates, says the World Factbook of the U.S. Central Intelligence Agency. It’s the second highest in South Asia, after Afghanistan.

According to the 2021 maternal mortality report (which was updated in 2023), the top direct cause of maternal deaths in Nepal is obstetric hemorrhage (26%), the majority of which is postpartum hemorrhage (PPH). The second most common cause is hypertensive disorders in pregnancy, childbirth, and the puerperium (12%), while the third is pregnancy-related infection (7%). Other obstetric complications (6%) share fourth place with intentional self-harm.

In 2009, the government launched a nationwide program to prevent PPH by providing the drug misoprostol in advance to pregnant women. 

But for many reasons the planned nationwide rollout of the drug misoprostol faced challenges. In 2019, the Nepal Safe Motherhood and Newborn Health Road Map 2030 recommended that the program be scaled up. 

Yet just a year later, as COVID-19 hit Nepal, there was such a shortage of the drug that the government had to appeal to international partners for emergency supplies. They arrived at the end of 2020. 

Current supplies of misoprostol are still unreliable, and the program has reached only 56 of Nepal’s 77 districts. Observed Dr. Saroja Pande, president of the Nepal Society of Gynaecologists and Obstetricians, in a 2024 interview: “The difference between the past and now is that most of the PPH deaths happen in facilities, not in the community.”

The gynecologist said that while the misoprostol program should continue, it should be in parallel with redoubled efforts to prevent PPH in facilities. These have started, she said, and include training frontline workers on the management of delivery complications like PPH, both during normal childbirth and caesarean sections. 

Workers are also being trained to use anti-shock suits, another measure introduced last year by the Family Welfare Division (FWD) of the Department of Health Services.  Designed to prevent shock and push blood away from the uterus, the suits can keep a woman alive for up to 48 hours; without one she could “bleed out” in 30 minutes, says UNICEF. FWD bought 40 suits for facilities in high-risk districts. 

“Definitely we are still looking for ways to address PPH,” Pande said. “What we’ve done is still not enough.”

“The government is quite keen to address PPH” and “working positively with us,” Pande said. But she noted that one barrier to addressing these issues is politics. Governments change frequently, leading to disruptions in the health system.

Pande adds: “We plan something in one place and suddenly the whole set-up (personnel) changes. So, again, we have to go advocate with a new management team to approve our activities.”

Source: UNICEF

Unaddressed flaws

Like Pande, Dr. Swaraj Rajbhandari, an obstetrician who led a review of the misoprostol pilot project in 2010, thinks that misoprostol distribution should continue. “I definitely believe we still need community-based intervention,” she said. But she stresses that facility-based care shouldn’t be neglected.

“They go hand in hand,” Rajbhandari said. “If there’s a complication and a pregnant woman is sent to the hospital and the hospital is not well equipped to manage complications, that is where we are losing mothers.”

There is actually a new project to build maternal health simulation labs in seven referral hospitals nationwide – starting with Maternity Hospital – that receive difficult cases from other facilities. 

Bhatta, however, said that funding for the labs had been provided by the U.S. Agency for International Development (USAID) via One Heart Worldwide, and has been cut. The organization is scrambling to replace the $1.2-million budget. 

USAID had been funding many other programs in the Department of Health Services, department director Dr. Bibek Kumar Lal told the Kathmandu Post. “The impacts of fund cuts may seem insignificant in the initial stage,” he said, “but … years of progress will be jeopardized if we discontinue ongoing programs.” 

Asked about the simulation labs project that has suddenly been defunded, Rajbhandari said, “It is important to practice normal births, resuscitation of newborns, and other situations, because these are some of the most critical things that healthcare workers are not confident about. For that, all these simulation-based labs are crucial.”

Other innovations launched recently by the FWD to improve MNCH include translating into Nepali a global app designed to provide advice to healthcare workers facing immediate problems. Subsequently, half of the new downloads of the app were in Nepali with the other half in the original English version. The top users were workers in primary care facilities, according to data provided by U.N. Population Fund (UNFPA) Nepal.

Rajbhandari is generally appreciative of such initiatives, but noted that systemic problems persist in Nepal’s healthcare system that can lessen their impact. “For example,” she said, “I still get calls because of the telemedicine project that I worked on. (The healthcare worker) will say, ‘This woman has been in full labor with no progress for the last four or five hours – what should I do?’”

“My question to them is always, ‘Why did you wait so long?’ You’re not supposed to wait for more than an hour. Because by the time you refer, it will take another two – three hours, if you’re lucky, if the health facility is nearby. So the clinical decision-making skill of these workers is still lacking,” she added.

For former health secretary Roshan Pokharel, though, governance is the main roadblock to progress in Nepal’s healthcare system. 

“I used to look after all the 77 districts, all the 205 primary health care centers,” he told Asia Democracy Chronicles in an interview two days before he retired from his post recently. “All the district hospital people came to us. Because of federalism, that chain has been broken.” 

In 2015 Nepal adopted a federal system, and the responsibility for providing healthcare was transferred largely from the national to local governments. 

“The referral mechanism is not working,” said Pokharel. “Before, the most basic facility was the sub-health post. If people went there and needed more advanced treatment they would go to the health post, then to a PHC (primary health center). Then they went to the district hospital. This chain has been broken now. Local people want to come directly to the center rather than going to the district hospital.” 

Meanwhile, he said, local governments want to build more health facilities but continue to argue with Kathmandu about which level of government will fund the personnel to staff them. As a result, widespread staff shortages persist. ◉