Nepal

Nepal maternal mortality and morbidity study 2008/09 - Summary of preliminary findings

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KEY FINDINGS

- The overall Maternal Mortality Ratio (MMR) for the eight study districts is 229 per 100,000 live births, ranging from 153 to 301 by district. This is consistent with the 2006 Nepal Demographic and Health survey (NDHS) estimate of 281 per 100,000 live births.

- MMR variations: The MMR was lowest amongst women in their twenties, with increased risk for those aged under 20 and between 30-34. The figure for those aged over 35 was considerably higher (962 per 100,000 live births). There were also differences between ethnic groups, with higher rates among Muslims, Terai /Madhesi and Dalits.

- Maternal causes accounted for 93% of pregnancy related deaths, giving an overall pregnancy related mortality ratio of 247 per 100,000 live births and making this a good proxy indicator for maternal mortality.

- Maternal causes accounted for 11% of all deaths of women of reproductive age, in third place by ICD-X chapter; down from 21% in 1998, when it was the leading cause by ICD-X chapter.

- There has been a dramatic increase in the contribution of suicide (16%) to deaths of women of reproductive age, compared with 10% in 1998. This makes it the leading single cause of death, whereas in 1998 it was third.

- Direct causes accounted for 69% of all maternal deaths and 31% were due to indirect causes. The proportion of direct deaths is considerably higher when only hospital deaths are considered (89% direct; 11% indirect).

- The percentage contribution of haemorrhage (24%) to maternal causes has been dramatically reduced, down from 41% in 1998. However, it remains the leading cause of maternal death, and the decline reflects a reduction in postpartum (from 37% to 19%), rather than antepartum.

- The percentage contributions of eclampsia, abortion related complications, gastroenteritis and anaemia to maternal causes have increased, while those from obstructed labour and puerperal sepsis have more than halved since 1998. Heart disease did not even feature in 1998, but now accounts for 7%.

- Place: There was an increase in the proportion of pregnancy related deaths occurring in a health facility, to 41%; with 40% occurring at home; and 14% in transit. In 1998 just 21% of deaths occurred in facilities and 67% at home.

- Timing: All non-maternal pregnancy related deaths occurred during the antepartum period. Many were unwanted pregnancies, suggesting the pregnancy status of the women may have placed them at greater risk. Of the maternal deaths, 39% occurred during the intrapartum period and up to 48 hours afterwards and 61% in the antepartum and postpartum periods suggest that interventions should focus more on this period.

- Over 80% of women who died from maternal causes were emergency admissions and in a critical state on admission: 18% died within four hours of arrival, 39% within the first twelve hours and 53% within the first 24 hours.

- Supply side factors contributing to poor maternal outcomes included continued use of practices which are not evidence based, lack of appropriate staff; lack of essential drugs; weak referral systems and lack of blood.

- Community factors contributing to poor maternal outcomes included delays in recognising the problem and deciding to seek care; long distances to a health facility; lack of finance and/or transport or time taken to make arrangements; seeking care from the informal sector; not being able to or not wanting to seek care alone or needing permission to seek care.