Maternal & Newborn

status in Nepal
Introduction
 
• Health care services during pregnancy and
childbirth and after delivery are important for
the survival and well-being of both the
mother and the neonate.
• The National Safe Motherhood Program is a
priority area for the government of Nepal to
improve maternal and neonatal health.
• As part of this program, the National
Neonatal Health Strategy was endorsed in
2004 to provide guidelines on improving
neonatal health.
• Likewise, a policy on skilled birth attendants
(SBAs) endorsed in 2006 by the MOH
identified the importance of SBAs at every
birth and lived the government of Nepal’s
commitment to training and deploying
doctors, nurses, and auxiliary nurse midwives
with required skill across the country.
• In 2008-2009, the birth preparedness package was
rolled out in all 75 districts to improve timely access to
delivery care services.
• Similarly, a maternity incentive scheme was
introduced in 2005 to encourage women to use health
facilities for maternity care and improve access to
maternity care services.
• In 2016, the government of Nepal endorsed the
country’s Every Newborn Action Plan, which sets a
vision for the country “in which there are no
preventable deaths of newborns or stillbirths, where
every pregnancy is wanted, every birth celebrated, and
women, babies and children survive, thrive and reach
their full potential.”
 Maternal health status
1.Antenatal care coverage
Skilled Providers
• Overall, 84% of women received ANC from a
skilled provider (2016)(43%by doctors, 41 % by
nurses or ANMs)
• Overall ,58% of mothers received antenatal care
from a skilled provider (2011)
• Overall ,44% of mothers received antenatal care
from a skilled provider (2006)
• Overall ,28% of mothers received antenatal care
from a skilled provider (2001)
• In 2016, women under age 20 were more likely
(87%) to use ANC services from skilled
providers than their older counterparts age 35-
49 (67%).
• The use of ANC services from skilled providers
was highest in Province 7 (91%) and lowest in
Province 6 (73%).
• Notably, doctors were the major service
providers in Province 2 and Province 3, while
the main providers in Province 6 and Province
7 were nurses or auxiliary nurse midwives.
 
Timing and Number of ANC Visits
 
• 69% of women had at least four ANC visits (2016)
• 50% of women had at least four ANC visits (2011)
• 29% of women had at least four ANC visits (2006)
• 14% of women had at least four ANC visits (2001)
• The Ministry of Health recommends that a
pregnant woman have ANC visits at least four
times during her 4th, 6th, 8th, and 9th months.
Pregnant woman who had an antenatal checkup,
59% received ANC during all four of the
recommended months(2016)
ANC during the first trimester of pregnancy

• 65% of women received ANC during the first

trimester of pregnancy ( 2016 )
• 50% of women received ANC during the first
trimester of pregnancy (2011)
• 28% of women received ANC during the first
trimester of pregnancy (2006)
• 16% of women received ANC during the first
trimester of pregnancy ( 2001)
2. Components of ANC visits
 
According to NDHS 2016
• Among women who received ANC, 91% had
their blood pressure checked,
• Urine samples were taken from 75% of the
women
• Blood samples were taken from 66% of the
women
• It should be noted that blood and urine
sampling require laboratory services that are
not available at all health facilities.
• 91% took iron tablets or syrup and 69% took
intestinal parasite drugs during the pregnancy
 
According to NDHS 2011
 
• 86% of pregnant women had their blood
pressure taken.
• 56% of pregnant women had taken urine
sample.
• 45 % of women had blood taken for testing,
• 80% of women took iron tablets and 55 % of
women took intestinal parasite drugs during
pregnancy
 
Counseling Components of ANC
According to NDHS 2016
 The survey also collected information on
counseling services provided during ANC visits
with respect to five components:
• Using a skilled birth attendant during the
delivery,
• Having an institutional delivery,
• Danger signs during pregnancy,
• Where to go if there is danger signs during the
pregnancy,
• The importance of getting a postnatal check.
 Only half of women (49%) received counseling
on all five components.
 Among the five areas, the need to get a
postnatal check was least likely to be
discussed during ANC (59%).
 
According to NDHS 2011
 
• 32% of pregnant women who were informed
of complications during pregnancy
3. Protection against neonatal tetanus
•  Overall, 89% of live births were protected
against neonatal tetanus (2016)
•  82 % of live births were protected against
neonatal tetanus (2011)
 
4. Delivery services
 
Institutional Deliveries
In NDHS 2016
• Nepal is promoting safe motherhood through
initiatives such as providing free delivery care
and transportation incentive schemes to
women delivering in a health facility.
• financial support are also provided to health
facilities for free delivery care on the basis of
deliveries conducted.
 57% of births were delivered in health facilities
• 43% of deliveries took place in government
facilities and
• 10% of deliveries took place in private facilities
In 2011 NDHS

 35% of births take place in a health facility:

• 26 % are delivered in a public-sector health facility,
• 2 % are delivered in a nongovernment facility,
• 7 % are delivered in a private facility.
 
Institutional deliveries by province
Reasons for Not Delivering in a Health Facility
•  56% of Women reported that it was not
necessary to deliver in a health facility. It was the
most common reason.
• 18% of women reported that the birth taking
place before reaching the facility.
• 17% of women reported that the facility was too
far away or not having transportation.
• 80% of mothers in Province 2 said they felt that it
was not necessary to deliver in a health facility.
• In Province 7, 38% of mothers said the birth took
place before reaching the facility.
Skilled Assistance during Delivery
 
In 2016 NDHS
 Assistance from a skilled birth attendant during
delivery is considered a key factor in reducing
maternal and neonatal mortality.
• 58% of deliveries are conducted by a skilled
provider
-31%of deliveries are attended by doctors
-27% of deliveries are attended by nurses
or auxiliary nurse midwives
• 20% of deliveries are attended by
relatives/friends
• 5% of deliveries are attended by Traditional birth
attendant
• 4% of deliveries are attended by HA/AHW/MCHW
• 3% of deliveries are attended by FCHV
• 10% of deliveries are attended by no-one

In 2011 NDHS
 36% of births take place with the assistance of a
skilled birth attendant (SBA), which includes
doctor, nurse, or midwife.
• 4 % of births take place with the assistance of
Health assistants or AHWs
• 3 % of births take place with the assistance of
FCHVs
• 11 % of births take place with the assistance
of traditional birth attendants
• 40% births are attended by a relative or
some other person,
• 3% of births take place without any type of
assistance.
 
Delivery by Cesarean

In NDHS 2016
Access to cesarean sections can reduce maternal
and neonatal mortality and complications of
labor. WHO advises that cesarean sections be
done only when medically necessary and does
not recommend a target rate for countries to
achieve at the population level.
• 9% were delivered by cesarean section
• 5% of total births, the decision to deliver by C-
section were made before the onset of labor
pains. 
• The cesarean section delivery rate is
considerably higher for births in private
facilities (35%) than in public facilities (12%).
• C-section deliveries are twice as prevalent in
urban areas (12%) as in rural areas (6%).
• C-section deliveries account for only 2% of
births in Province 6, as compared with 17%
each in Province 3 and Province 4.
In NDHS 2011
 
• 5 %t of births is delivered by cesarean section.
• Delivery by cesarean section is highest among
births to highly educated mothers (13%)
• Births to mothers in the highest wealth quintile
(14%), urban births (15%), and first births (7%).
• Among births delivered by cesarean section,
12% were planned, while the rest was carried
out due to complications at delivery (data not
shown).
 Care and Support during Delivery
 
In 2016 NDHS
National and global evidence suggests that
postpartum hemorrhage is one of the leading
causes of maternal mortality.
In Nepal, the Ministry of Health has initiated the
use of prophylactic oxytocin immediately after
birth under the Active Management of Third
Stage Labor intervention program.
• Among all births assisted by a health
professional, 53% of mothers received an
injection or medicine through an intravenous
drip during labor.
• This proportion was higher among births in
Province 2 (70%) than births in other
provinces.
• Likewise, 51% of mothers whose births were
assisted by a health professional received an
oxytocin injection after the delivery,
• 12% point decline from 2011. According to
NDHS 2011,63 % of mothers who had a live
birth and were assisted by health personnel
received an oxytocin injection immediately
after delivery
•  Only 42% of mothers in Province 1 received
oxytocin, as compared with 60% of mothers in
Province 5.
a. Support during Delivery
  In NDHS 2016
 In 2009, a national free delivery policy known as
the Aama program was launched in Nepal to
address the financial barriers women face in
accessing health facilities for delivery. Moreover,
a cash incentive scheme, the Safe Delivery
Incentive Scheme, was initiated in 2005.
• It provides cash payments to women who
deliver in government and selected private
health facilities and incentive payments for
health workers who undertake deliveries.
• Women who delivered in a health facility, 76%
of women received a cash incentive for
transportation to the facility.
• In Province 2, only 66% of women received the
transportation incentive, whereas in Province 7
the proportion was much higher (96%).
 
• The fact that the Aama program has been
implemented only in selected private health
facilities has an impact on differences
 
NDHS 2011
• 71% of mothers received payment to release
the cost of transportation to a health facility.
• 73% of rural women received transportation
incentives, compared to 60% of urban women.
• Women at higher levels of education and
wealth were less likely to use free services
provided by the government.
b. Postpartum Hemorrhage Prevention in2016
NDHS
 
• Matri Surakshya Chakki is a misoprostol tablet that
is distributed to women to prevent postpartum
hemorrhage if delivery in a health facility is not
planned and the birth is not assisted by a health
professional.
• Three misoprostol tablets (600 mcg) are given to
pregnant women to take immediately after delivery
and before the placenta is expelled (MOH 2015).
• 
• 14% of women with a live birth was
not assisted by a health professional
received the tablets and 13% took
them.
• Only 42 out of 75 districts had
implemented the Matri Surakshya
Chakki program
c. Birth Preparedness
•  The Ministry of Health has
implemented a birth preparedness
package that outlines actions mothers
and household members should take
to prepare for the birth.
• The major aim of this package is to
reduce delays in accessing delivery
care services.
• The guidelines recommend that families save
money for emergencies, arrange transportation
beforehand based on local conditions, identify
persons who can and are eligible to donate blood
if required, identify and contact health facilities
and health workers who can provide services, and
have a clean delivery kit available (USAID 2010).

According to 2016 NDHS

•  62% of women had saved money for their birth
• 15% of women had arranged for transport.
• 16% of women reported that they had not
made any of the preparations mentioned in the
package.
• There was an increase in saving money in
preparation for delivery between 2011 and
2016, from 36% to 62%.
 According to 2011 NDHS
•  36 % of women saved money for delivery.
• 5% of women bought a home delivery kit and
• 2 %of women contacted a health worker, which
are reductions in comparison to similar data in
the 2006 NDHS.
• 56% of women arranged for food and clothing
for the newborn in comparison to 26 % in 2006.
• 34% of women said they had not made any
preparations at all for the birth of their child.
• Arrangements for transportation increased from
1 % in 2006 to 3% in 2011.

d. Time Taken to Reach the Health Facility

2016 NDHS
 29% reached the health facility within 30 minutes
and 45% reached the facility in 30 to 60 minutes.
• 25% of women traveled more than 1 hour to reach
the facility;
• In the mountain zone, 42% of women had to travel
more than an hour.
According to 2011 NDHS
• 28% of women took less than 30 minutes to reach a
health facility, 27% took 30-60 minutes, and 45%
took more than one hour.
• 50% of women took more than one hour to reach a
health facility for delivery.
• 40% of women in the hill zone and terai reported
that it took them more than one hour to reach a
health facility.
5. POSTNATAL CARE
 
a. Postnatal Health Check for Mothers
In 2016 NDHS

• The postnatal period is important for mothers,

as evidence has shown that they are more
likely to develop life-threatening
complications such as postpartum
hemorrhage during this period.
• Postnatal visits from health personnel can
help to prevent or treat most of these
conditions.
• In addition, this period is important for
counseling mothers on how to care for
themselves and their newborns.
• It is recommended that a woman receive at
least three postnatal checkups, the first
within 24 hours of delivery, the second on
the third day following the delivery, and the
third on the seventh day after delivery.
• 57% of women reported having received a
postnatal check in the first 2 days after the
birth,
• 42% of women did not receive any postnatal
check.
• The proportion of women with a postnatal
check within 2 days after delivery increased
from 45% in 2011 to 57% in 2016.
Type of Provider
2016 NDHS
 
• Postnatal care from a skilled provider is important to
diagnose problems or complications during the
postpartum period and recommend appropriate
treatment or referral.
• More than half (53%) of women who gave birth
received their first postnatal care from a doctor, nurse,
or auxiliary nurse midwife.
• In the mountain zone, 6% of women received their first
postnatal care from a female community health
volunteer, as compared with less than 1% of women in
the hill and terai zones
 2011 NDHS
• 23 % of women received postnatal care from a nurse or
midwife and 16% from a doctor.
• 6% of women received postnatal care from a health
assistant, AHW, MCHW, VHW, or FCHV.
• Postnatal care from an SBA was highest in the terai, in
the Eastern region, and in the Eastern terai subregion.
 Place of First Postnatal Check (2016)

• Among women who gave birth, 39% reported that their

first postnatal check was provided in a government-
sector facility and 10% reported receiving care from the
private sector
 
Postnatal Health Check for Newborns
In 2016NDHS
 
• Proper care for newborns is essential to
reduce neonatal problems and death.
According to the World Health Organization,
postnatal care services for newborns should
start as soon as possible after birth because
many neonatal deaths occur within the first
48 hours of life (WHO 2015).
• To identify, manage, and prevent
complications, the government of Nepal
recommends at least three postnatal
checkups for newborns within 7 days of
delivery, which is considered a critical time
period for neonates and mothers.
• 50% of newborns received a postnatal check
within the first 2 days after birth.
• One in five newborns (21%) had a postnatal
check within the first hour of life
In 2011 NDHS

• 30% of newborns were taken for their first

postnatal checkup within the critical first two
days after birth.
• 23%of newborn had a postnatal checkup
within three hours after birth
• 28% of births had a postnatal visit within 24
hours after birth.
• The majority of newborns (68 %) did not
receive a postnatal checkup.
•  Newborns delivered outside of a health
facility were less likely to receive a postnatal
checkup within the first week after birth
(11%) than newborns delivered in a health
facility (58%).
• Similarly, postnatal checkups were less likely
among births to mothers age 35-49, births of
order six and over, rural births
Type of Provider
In 2016 NDHS

• 51% of newborns received their first postnatal

check from a doctor, nurse, or auxiliary nurse
midwife.
• The proportion of newborns with a postnatal
check by a doctor, nurse, or auxiliary nurse
midwife was higher among first births (65%),
those whose mothers had an SLC or higher
(71%), and those born to mothers in the
highest wealth quintile (72%)
In 2011 NDHS
• 25% of newborns received postnatal care in the
two days following birth from a doctor, nurse, or
midwife.
• 4% of newborns received care from a health
assistant, AHW, MCHW, or VHW.
• 2% of newborns received care from an FCHV.

Place of First Postnatal Checkup 2016

• 41% of infants born received their first postnatal
care from the government sector, while 10%
received care from the private sector
Newborn Care Practices
 
Components of Newborn Care
In 2016 NDHS
 
• 44% of infants born had their umbilical cord
examined,
• 43% of infants had their temperature measured.
• Only 34% of mothers received counseling on
newborn danger signs
• 50% of mothers were counseled on
breastfeeding and observed while
breastfeeding.
• 63% of newborns were put immediately after
birth on the bare skin of the mother’s chest or
belly. (KMC)
• Nearly 9 out of 10 newborns were dried (87%)
or wrapped in cloth(88%) before the placenta
was delivered.
• 70% of newborns were not bathed until 24
hours or longer after the birth.
2011 NDHS
 
• Asked mothers with non-institutional
deliveries about the newborn care practices
they adopted.
• 59% of newborns were wiped before the
placenta was delivered a
• 62% of newborn were wrapped in cloth;
 
• Only 10%of newborn were placed on the belly or
breast of the mother before the placenta was
delivered.
• Immediate wiping, skin-to-skin contact, and
wrapping are more frequent among urban women
and among those in the Far-western region.

• One in four newborns( 24%) being bathed only after

24 hours post-birth compared with only 9% in 2006.

 
Cord Care
In 2016NDHS
 
• Umbilical cord infection is a contributory cause of
neonatal morbidity and mortality. Cord infection is
of particular concern for births delivered at home.
• 18% of non-institutional deliveries, instruments
from a safe delivery kit were used to cut the
umbilical cord, a 4-percentage-point increase from
2011.
• In 70% of non-institutional births, a new or boiled
blade was used to cut the umbilical cord.
• Among all live-born infants, 63% had
something placed on the stump after cutting of
the umbilical cord.
• Chlorhexidine was applied on 39% of
newborns, and ointments and powders were
applied on 17%;
• 37% newborn had nothing applied on the
stump
• The highest proportion of newborns reported
as having chlorhexidine applied was in
Province 7 (61%), while the lowest proportion
was in Province 2 (24%).
• The indicator related to chlorhexidine must be
interpreted carefully, as only 58 districts had
implemented its use at both the health facility
and community levels by mid-2016.
• Among births with chlorhexidine applied on
the stump of the umbilical cord, mothers were
asked about the timing of application.
• More than two-thirds (69%) of newborns had
chlorhexidine applied within an hour of the
cord being cut, and more than 8 in 10 had
chlorhexidine applied within 2 hours
In 2011 NDHS
• New/boiled blade was used to cut the
umbilical cord in 68% of non-institutional
births.
•  Clean home delivery kit were used in 14 % of
births.
•  A hasiya (sickle) was used in 11 % of births,
• 4 % were exposed to used, unsterile blades.
• 41% of babies had some material (usually oil,
an ointment, turmeric, or ash) placed on their
umbilical stump.
• Only 2% of babies had chlorhexidine ointment
placed on their stump after cutting of the
umbilical cord (data not shown).
• 19% of babies had an unknown
ointment/powder placed on their stump.
 
Pregnancy Outcomes

• 81% of pregnancies resulted in a live birth.

• 9% of pregnancies were aborted, and a similar
proportion resulted in miscarriages;
• 1% of pregnancies were ended in stillbirths .

Reference
• NDHS 2016 & 2011