REVIEW Family Medicine and Community Health REVIEW Maternal health and its affecting factors in Nepal Gehendra Mahara1,2, Jill Barr3, Janeeta Thomas4, Wei Wang1,2,5, Xiuhua Guo1,2 Abstract 1. Department of Epidemiology Maternal health is still a public health problem in developing countries, especially in low-re- and Health Statistics, School of source settings rural and poor communities. The main aim of this article is to critically evaluate and Public Health, Capital Medical explore the situation of maternal health in Nepal based on published or unpublished governmen- University, Beijing, China tal or nongovernmental organization’s scientific reports regarding maternal health. We found that 2. Beijing Municipal Key Labo- ratory of Clinical Epidemiology, there were several direct or indirect causes and affecting factors of maternal death in Nepal, which Beijing, China are preventable. Women have been facing different consequences during pregnancy and delivery, 3. School of Health and Well– attributed to lack of proper knowledge or less available and affordable health facilities in rural Being, University of Wolver- communities. Therefore, there is needed an essential maternal health knowledge to women and also hampton, UK establish health facilities with a quality health care service on affordable and accessible to prevent 4. Ashwani Ayruvedic Hospital, maternal death and minimize complications. Kerala, India 5. School of Medical and Health Sciences, Edith Cowan Univer- Keywords: Maternal health; maternal mortality; Nepal sity, Perth, Australia CORRESPONDING AUTHORS: Xiuhua Guo, PhD General information Approximately 830 women die per day Department of Epidemiology Maternal health is the health status of women worldwide of pregnancy-related causes, and Health Statistics, School of during pregnancy, childbirth, and the post- which can be prevented. Remarkably, 99% Public Health, Capital Medi- partum period, which incorporates the health of maternal deaths happen in develop- cal University, No.10 Xitoutiao, You’anmen Wai, Fengtai Dis- care dimension of family planning, precon- ing countries, mostly in low-resource set- trict, Beijing 100069, China ception, and prenatal and postnatal care to tings, rural areas, poor communities, etc. Tel.: +86-10-83911508 reduce maternal morbidity and mortality [1]. The World Health Organization estimated Fax: +86-10-83911508 Correspondingly, maternal death refers to that 303,000 women worldwide will have E-mail: [email protected] death of a woman while she is pregnant or died by the end of 2015 during and follow- Gehendra Mahara, PhD Fellow ing pregnancy and childbirth. Millennium within 42 days of termination of pregnancy, Department of Epidemiology irrespective of the duration and the site of Development Goal 5 was adopted in 2000 and Health Statistics, School of the pregnancy, from any causes related to by the international community to improve Public Health, Capital Medical or aggravated by the pregnancy or its man- maternal health and reduce maternal mor- University, No. 10 Xitoutiao, You’anmen Wai, Fengtai Dis- agement but not from accidental or inciden- bidity and mortality. Recently, a report by trict, Beijing 100069, China tal causes according to the World Health the World Health Organization [1] revealed E-mail: [email protected] Organization [1]. It should not be due to any that maternal death has dropped by 43% chronic disease or condition. Mostly maternal worldwide; however, maternal death Received 15 December 2015; death occurs in developing countries rather is still high in sub-Saharan Africa and Accepted 5 January 2016 than developed countries. South Asia. Family Medicine and Community Health 2016;4(3):30–34 30 www.fmch-journal.org DOI 10.15212/FMCH.2015.0155 © 2016 Family Medicine and Community Health REVIEW Mahara et al. There are two different types of causes of maternal death: Factors influencing maternal mortality direct and indirect. Direct causes of maternal morbidity Home delivery and death are hemorrhage, infections, high blood pressure, Home delivery is the factor most influencing maternal mor- eclampsia, preeclampsia, unsafe abortion, and obstructed tality in Nepal [11]. The Nepal Demographic Health Survey labor, whereas previous existing diseases or conditions such [3, 12] and Sreeramareddy et al. [12] reported that almost as cardiac diseases, renal disease, and hormonal disorders are 90% of births occurs at home and that a skilled health worker indirect causes of maternal death [1]. is most important in the community to conduct delivery safely in the home setting, which can help reduce the risk Maternal mortality ratio in Nepal of maternal complications and maternal death. The percent- Nepal had the highest maternal mortality ratio among South age of home deliveries is still high in Nepal, where 63.1% of Asian countries in 1990 (850, 539, 415, 281, and 229 per deliveries occur at home and only 35.3% of deliveries occur 100,000 live births in 1990, 1996, 2001, 2006, and 2011, in a health facility [13]. It is most necessary that first-time respectively [2–4]). It had been estimated that the ratio will be delivery should be in a health facility or if delivery takes 170 per 100,000 live births by the end of 2015. Nepal received place at home that a skilled health professional should be the Millennium Development Award for recognition of its suc- there or that within 2 hours of delivery the mother visits a cess in reducing maternal mortality in 2010 [5]. However, the health facility or a skilled health professional to reduce the ratio is still high in comparison with the ratios in developed complications of delivery suggested by the World Health countries and other developing countries. Moreover, Dhakal Organization [1]. The World Health Organization [1] report [6] showed that the decline is not evenly spread across the on the risk of home delivery has strongly suggested that first- country, maternal health have not improved in poor communi- time delivery should be in a hospital otherwise a women will ties and rural areas. be three times likelier to suffer a complication if she delivers in a home setting. Causes of maternal death in Nepal According to the Nepal Maternal Morbidity and Mortality Unsafe abortion Study (2008–2009) [7] the leading causes of maternal death Unsafe abortion is one of the direct causes of maternal death in Nepal were hemorrhage, then eclampsia, abortion-related in Nepal. Thapa et al. [14] stated that unsafe, unhygienic, complications, gastroenteritis, and anemia. This study reported and sometime dangerous practices have been undertaken in that 69% of maternal deaths were due to direct causes and rural parts of Nepal and because of the consequences unex- the remaining 31% were due to indirect causes. Almost the pected maternal deaths have been occurring in Nepal [15]. same finding was revealed by Bhandari and Dangal [8], who This is due to the lack of proper safe delivery knowledge, identified postpartum hemorrhage, unsafe abortion, infection, lack of awareness about health, and unavailable health ser- preeclampsia, and long obstructive labor as the major causes vices in rural communities [16]. The Family Health Division, of maternal death in Nepal. Postpartum hemorrhage and long Departmental of Health Services, Ministry of Health and obstructive labor were the main causes of maternal death in Population (MOHP), Nepal, has been providing a safe abor- rural areas, whereas unsafe abortion, infection (particularly tion service to terminate unwanted pregnancies through a hepatitis E), and hypertension with preeclampsia were the safe procedure with effective management at the community main causes of maternal death in urban areas [8]. Septic abor- level, according to the World Health Organization guide- tion was the leading cause of maternal death in Kathmandu lines [17]. Abortion has been legal in Nepal since 2002, and Valley in the study of Rana et al. [9]. Too young and too old since then services have been offered in public hospitals or maternal age, high parity, malnutrition, and illness in early health centers with trained health professionals. However, midgestation were the underlying causes of maternal death in the impact of the safe abortion service has not been reported the countryside in Nepal as found by Christian et al. [10]. extensively to date. 31 Family Medicine and Community Health 2016;4(3):30–34 REVIEW Maternal health and its affecting factors in Nepal Traditional birth attendants associated with maternal mortality as reported by Bongaarts Traditional birth attendants (TBAs) are also a factor affecting and Johansson [21]. maternal health in Nepal. They are not well trained to conduct delivery safely in the context of a quality health care service. Health services and affordability They use traditional methods to conduct the delivery at home, The lack of health services and the quality of the health care and that practice puts the health of women in danger. However, service are the key factors to reduce maternal mortality, as TBAs have been playing a vital role in the community during stated by Bolam et al. [22] and Jahn et al. [23]. The patient antenatal care, delivery, and the postnatal period [16]. Women flow is huge, but health workers are very few. Therefore, can benefit easily from them in the community and the cost of patients have no privacy to explain the problems to the health their service is also less than the cost of other private or gov- worker in outpatient department (OPD) in the hospital [16]. ernment health workers [18, 19]. Health care workers are not well trained or qualified, and due TBA can be found everywhere in Nepal [16]. TBAs are to improper skilled they cannot maintain confidentiality and a source of maternal care during pregnancy and delivery the privacy of women [24]. Nepal is an underdeveloped coun- because of insufficient trained professionals in rural parts try; therefore, people cannot afford the cost of essential health of the country. The services are different according to cast services. In addition, in a study on the use of antenatal care and culture among the TBAs.