A CALL FOR ACTION TO FURTHER IMPROVE MATERNAL HEALTH AND REDUCE MATERNAL DEATHS IN NEPAL

1. Nepal received the Millennium Development Goals (MDGs) award in 2015 for the remarkable progress in the last two decades in decreasing maternal deaths and 7 improving women health. This achievement is a ributed to the Safe Motherhood program including the strengthening of the birthing centers; Aama Surakshya program promo ng antenatal check-ups and ins tu onal deliveries; expansion of the 24 hour emergency obstetric care services and safe abor on services. Under the Aama program, women receive incen ves for four ANC visits/ postnatal care and transport incen ve for ins tu onal deliveries. All ins tu onal deliveries in Nepal are provided free of cost to the women and the government reimburses the health ins tu ons for the cost of the delivery care 6 services. Presently 58% deliveries are conducted by skilled birth a endants, 57% ins tu onal deliveries and 8 57% postnatal follow-ups .


A CALL FOR ACTION TO FURTHER IMPROVE MATERNAL HEALTH AND REDUCE MATERNAL DEATHS IN NEPAL
Pokharel HP , Budhathoki SS 1  2   According to the World Health Organiza on (WHO), "A maternal death is defined as death of a woman while pregnant or within 42 days of termina on of pregnancy, irrespec ve of the dura on and site of pregnancy, from any cause related to or aggravated by pregnancy or its management".Annually approximately half a million women die because of complica ons during pregnancy or childbirth and many of them encounter serious problems.The majority of these problems occur in developing countries, where poverty increases sickness and reduces access to care.These deaths occur within a context of gender-based, economic, poli cal and cultural services.
Most of these deaths are caused by hemorrhages, sepsis, hypertensive disorders, prolonged or obstructed labor, and 2 unsafe abor ons.The tragedy is that these deaths are largely preventable.The progress in maternal health has been uneven, inequitable, and unsa sfactory.The risk of a woman dying as a result of pregnancy and childbirth during her life me is about 1 in 6 in Afghanistan compared with 1 in 30,000 in Northern
The ra o of maternal mortality reveal large levels of inequity between and within countries -99 % of maternal deaths occur in developing countries and only 1 % of deaths in developed 4 countries.death toll, accoun ng Sub-Saharan Africa leads this for 50 % of all maternal deaths worldwide (900 deaths per 100,000 live births), and South Asia accounts for another 35 % (500 deaths per 100,000 live births), which is in extreme contrast with the high-income countries (9 deaths per 100,000  to increase in the coming years.

Interven on taken by Nepal Government to reduce
4. The decreased anemia among pregnant women because of free distribu on of iron capsules.
5. Financial incen ve for women who deliver babies in health ins tu ons.In Nepal, most births take place at home and many, par cularly in rural areas do not meet the recommended four prenatal visits.

Barriers to implementa on of a standard maternal health care in Nepal
• Geography imposes severe restric ons on the provision of health services in many low income countries where challenges exist in reaching popula ons in remote, 11 mountainous loca ons.In Nepal for example, the u liza on of a health facility for the delivery of a child is considerably lower in the mountains than in the country's two other ecological regions, the terai (i.e. the plains) and 6 the hills.Geographical inaccessibility to health services features in the mountains owing to scarce and dispersed popula ons, tough terrain with no transport or difficult 12 road condi ons, seasonal isola on, and remoteness.
• Limited public awareness of the importance of antenatal check up and compulsory ins tu onal deliveries to reduce any unwanted pregnancy complica ons.
• Limited access to primary and specialized obstetrics services.There is mal-distribu on of health services, with specialized health services being available only in the major ci es of the country.
• Low literacy rate of 57% and 66% in females and males respec vely, many Nepalese pa ents may not have the capacity to obtain and understand the basic health informa on necessary to be able to make appropriate 13 health decisions.One of the biggest challenges to improving health outcomes is educa ng women and empowering them with the health knowledge necessary to seek appropriate health care and make informed decisions.
Apart from the above barriers, Cultural, religious and tradi onal health prac ces plus the economical barriers add 14 to the challenges.

A promising way forward to improve maternal health
1. Consistent poli cal will.
2. Universal Na onal health programme to combat maternal mortality.
4. Skilled birth a endance at most deliveries Increase in .female trained community workers has yet to be widely implemented, especially to rural areas of the country.
5. High quality of care from trained midwives a ributed to decrease in MMR Ac ve midwife commitment to mother .and child health and their approach is an inspira on to 15 South Asia.

Studies have shown that prenatal care helps to reduce
maternal mortality through iden fica on of poten al risks earlier, thus, allowing planning for safe delivery.
7. School Health Programme includes assessments of nutri onal status, detec on of health problems and provides immuniza on in young adolescent girls.
8. Free school educa on without discrimina on for girls.This will contribute greatly to delaying the age at marriage, thereby reducing teenage pregnancies.Educa on also empowers women and gave them access to electronic and print media which have enabled them to have a greater 16 awareness regarding health.
9. The important health interven ons would be a gradual expansion and enhancement of the healthcare facili es ensuring easy accessibility of organized primary and 17 ter ary healthcare.
10. Conduc ng workshops and seminars concentra ng on management and preven on of post partum hemorrhage, eclampsia as well as the preven on of morbidity and mortality due to sepsis.
11. Equal distribu on of medical officers to all parts of the country. 18 Moving from the MDGs to the Sustainable Development Goals (SDGs) era, the health system of Nepal is gearing up to achieve the 'SDG3: Ensure healthy lives and promote well-being for all at all ages'.Maternal health is covered in the target of SDG3, which is set to reduce the maternal mortality ra o to less than 70 per 100,000 live births.The indicators to monitor this target are 'maternal mortality ra o' and live births a ended by skilled 17 birth a endants'.In order to meet this target by 2030, the Government of Nepal has projected to reach the MMR of 69 maternal deaths per 100,000 live birth and a ain the coverage of 90% of all births conducted by skilled birth a endants. 18ee ng the SDG3 depends on a mul tude of factors in health 17 including universal health coverage (UHC) , health literacy and 13 responsiveness of the health systems.With the popula on of Nepal reaching close to 30 million, 80% of the people living in rural areas, 15% of people living below the poverty line , UHC services index of 62%, health expenditures as Out-of-pocket expenditure as 60%, more than 10% people making catastrophic expenditure on health along with the ongoing restructuring of the federal health system together creates web of challenges that Nepal has to overcome in order to 18 achieve the targets set for the SDG3.Apart from pregnancy and its complica ons, women in Nepal are also facing a surge of the non-communicable disease (NCDs) like cancers and 9 cardiovascular diseases.While the health system is preparing to combat the NCDs, preparing the health system for addressing the gynecological cancers including the hereditary cancers also needs to be priori zed for discussions at policy 19 level.
Although the posi on of women has improved substan ally in Nepal over the past decades, progress has been uneven and mul ple challenges remain.Despite great improvements in health in the past 30 years, many women are yet to benefit.spending on health needs to be increased priori zing on the 'Best Buys' interven ons for maternal health, improving the quality of care and most importantly addressing the equity gap within the popula on.Iden fying the vulnerable in health has always been a challenge to ensure that 'no one is le behind'.Evidences have shown that collec ve effort of different governmental and interna onal organiza ons, educa on ins tu ons, local NGOs, mothers group, mass media to implement community-based interven ons have been successful to lower maternal deaths.Authori es need to emphasize not only in implemen ng of interven onal programs but also on keeping track of their success rates and drawbacks.Also, special considera on must be given to sustain such programs in the future.

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live births).The current trend of maternal mortality ra o gives an es mate of 5 women dying every day in Nepal due to pregnancy and its 6 complica ons.The Nepal Demographic Health Survey (NDHS) 6 2016 reports 239 maternal deaths per 100,000 live births which is a tremendous decrease from 901 maternal deaths per 7 100,000 live births in 1990.In 2017, maternal causes are ranked in the third place a er cancer and cardiovascular diseases for death among women of reproduc ve age (15-49 8, 9 years) in Nepal.
As there is good evidence that the exis ng interven ons are highly effec ve, the Safe Motherhood program needs to focus on increasing the popula on coverage of these services.Further to this, the Government of Nepal's Maternal mortality is a serious public health problem in Nepal and other developing countries.More than 80% of these deaths, which are caused by hemorrhage, sepsis, unsafe abor on, obstructed labor and hypertensive diseases of