Not seeking medical care before or after pregnancy. Births taking place without the attendance of healthcare workers. In such circumstances, as many as 830 women around the world are losing their lives every day during pregnancy and childbirth. Many countries worldwide face this problem, and improving maternal mortality is one of the Millennium Development Goals adopted by the United Nations in 2000 and one of the goals of the 2030 Agenda for Sustainable Development adopted in 2015. How can we ensure women’s health and safety during pregnancy and childbirth? One country that has drawn attention for markedly improving this common global issue is Nepal, a small landlocked nation in the Himalayas.

A town overlooking the Himalayas Photo: maxpixel.freegreatpicture.com [CC01.0]

Childbirth in the Himalayas: Challenges faced

What, fundamentally, causes maternal deaths? The main causes are hemorrhage during pregnancy, high blood pressure, and infections; in addition, unsafe abortion is also a contributing factor. In fact, medical responses to these causes have already been established, and in most cases they can be avoided through antenatal and postnatal checkups and by giving birth with healthcare professionals in attendance. However, as noted at the outset, when women do not visit medical facilities or give birth without the presence of healthcare workers, situations that should have been avoidable can develop and lead to maternal deaths.

From this, it should be clear why not seeking care around pregnancy and giving birth without skilled attendance are dangerous. The same circumstances exist in Nepal, the focus of this article. Why do such conditions that lead to maternal deaths arise in Nepal? The problem is closely tied to Nepal’s unique characteristics. As mentioned earlier, Nepal is located in the Himalayas, and 35% of its land area is mountainous. This steep topography severely limits transportation options. In addition, much of Nepal is rural; only 14% of the population lives in urban areas. Because of these uniquely Nepali features, there is a reality in which women find it difficult to access health facilities.

A caravan crossing an unstable suspension bridge Photo: Sergey Ashmarin [CC BY-SA 3.0]

Another contributing factor is the low status of women in Nepal. According to a UNDP report, Nepal ranks 144th out of 188 countries on the Gender Inequality Index. Nepali women are said to have little say within the household, and often must obtain permission from the head of the family to spend money—even when it is for medical services. In some regions, customs such as chhaupadi, which treats menstruating women as impure and isolates them from the household, still remain. In a country where many people believe that “childbirth should happen naturally,” negative views toward pregnant women receiving treatment are also observed. Insufficient understanding by women themselves and their families of the need for medical care keeps women away from health services.

What factors led to success

In Nepal, where such conditions persist, how did the country improve, and by how much? According to a World Health Organization (report), the maternal mortality ratio (※1) was a high 901 per 100,000 in 1990, but fell to 258 per 100,000 by 2015. This change moved Nepal from 158th out of 183 countries in 1990 to 139th in 2015.

As shown above, Nepal succeeded in dramatically improving mortality among pregnant women. What factors brought about this success?

The first steps were policies launched in 1991. Under the 1991 policy, many health centers and health posts that provide primary healthcare services were built, enabling people living in rural areas to benefit from modern medicine. In fact, the number of health posts increased from 351 to 1,204 over the 20 years from 1991 to 2011. In addition, the policy implemented in 2003 to legalize abortion played a major role in improving maternal health. Legalization not only gave women the right to make choices about sexual and reproductive health, it also enabled them to obtain abortions from trained providers, and a total of 900,000 women are said to have benefited from this policy. Then, in 2009, a policy was adopted to make the costs incurred during delivery free of charge, increasing the use of medical facilities. Nepal also addressed the access difficulties unique to high mountain areas by expanding roads, bridges, and other transport networks by 33% between 1999 and 2005, making it possible for rural residents to receive medical services.

Exterior of a health post Photo: Dskoich [CC BY-SA 4.0]

Of course, the government was not the only actor that played a major role in this “success.” The cooperation of supporters such as NGOs and the United Nations to solve this issue also had an impact. Consider the data below: Nepal received more assistance than other countries in South Asia. By proactively addressing maternal health issues, the government won the trust of supporters, and by actively implementing policies to mobilize support, it secured substantial assistance. In this way, the Nepali government was able to allocate significant financial resources to maternal health, leading to improvements in women’s health.

ODI report basis for compilation

In rural areas beyond the government’s reach, NGOs operate to fill the gap. For example, the government works with NGOs to organize “Mothers’ Groups” in every village to educate women about pregnancy and childbirth. Collaboration between organizations such as NGOs and the government made it possible to reduce maternal mortality.

：Women receiving education on health issues Photo: USAID U.S. Agency for International Development /Flickr [CC BY-NC 2.0]

Thanks to the efforts of the government, donors, NGOs, and citizens, the risks of childbirth in Nepal have been greatly reduced, and many women’s lives have been saved. Progress at the fundamental level—such as the advancement of women’s education and the accompanying changes in attitudes—can also be considered significant. However, many challenges still remain. As can be seen from the graphs above, although the maternal mortality ratio has greatly improved in Nepal, the gap with developed countries is still stark. In addition, many medical facilities were damaged by the 2015 earthquake, which has become a factor preventing pregnant women from receiving medical services. While many women have been freed from the risks of pregnancy and childbirth and can give birth safely, there are still women who continue to suffer without receiving these benefits. Can Nepal, which has made great strides in women’s health, achieve even further progress? We will continue to watch closely.

※1　Maternal mortality ratio: the number of deaths per 100,000 pregnant and postpartum women

※2　GNI (Gross National Income): the total income residents earn over one year from domestic and overseas sources

Writer: Tomoko Kitamura

Graphics: Tomoko Kitamura