93605 Knowledge Brief Health, Nutrition and Population Global Practice NEPAL: MATERNAL AND REPRODUCTIVE HEALTH AT A GLANCE Sameh El-Saharty, Naoko Ohno, Intissar Sarker, Federica Secci, and Manav Bhattarai November 2014 Country Context KEY MESSAGES: Nepal is one of three landlocked South Asian countries. In 2012, its population was 27 million and per capita income $1,470. The economy grew despite the 1996-2006 conflict • Nepal has made a remarkable progress but it did not accelerate post-conflict. Economic growth in achieving the MDGs – especially in slowed to 3.6 percent in FY13; a rebound to 4.5 percent is extreme poverty and education. expected in 2014. The economy is centered on subsistence agriculture. Remittances provide significant • Nepal has achieved MDG 5 but only household income—more than 25 percent of GDP. one in three births is attended by skilled Nepal has reduced poverty by 2.5 percentage points medical personnel. Disparities exist in yearly since 2004. It achieved MDG 1 by halving extreme access to maternal care by residence poverty. Since 2010-11, 25 percent of the population lives and wealth quintiles. below the poverty line, nearly a 30 percentage point drop 1, 2 from 1995-96. • The total fertility rate has declined to 2.4 in 2012, along with increased contraceptive The large youth population—36 percent under 15—is an opportunity to benefit from the demographic dividend. use at 50 percent. High unmet need of Nepal is likely to achieve most health-related MDGs. 27 percent still remains. Nepal achieved MDG 4 as the current U5MR and IMR is 41.6 and 33.6 per 1,000 live births. It has made excellent • Nutritional deficiencies for pregnant and progress in education. Net enrollment in primary lactating women remain a challenge. education increased from 64 percent in 1990 to 95.3 1, 2 percent in 2013. • Nepal has initiated a number of key Nepal eliminated gender disparities in primary and interventions to respond to increased secondary education. Women hold one in three national adolescents’ needs for health services, parliamentary seats. Wage employment by women in the improve accessibility and quality of non-agricultural sector more than doubled from under services at local level, and enhance 19.9 percent in 2009 to 44.8 percent in 2011. However, equitable access to services through the gender gap, especially in adult literacy, needs improvement: 71 percent for males and 46.7 percent for micro-planning exercise and provision females above age 15. Nepal ranks 102 of 148 countries of financial protection. in the Gender Inequality Index (2012). 3 Page 1 HNPGP Knowledge Brief  choice of contraceptives and are used by 43.2 percent of currently married women. Female sterilization (15.2 percent), injectables (9.2 percent) and male sterilization (7.8 percent) are the most commonly used form of modern methods. Traditional methods are used by 6.5 percent of currently married women. There is still an 5 unmet need of 27 percent. MDG Target 5a: Reduce the MMR by three-quarters, between 1990 and 2015 Nepal has made great progress over the past two decades on maternal health, resulting in its 1 achievement of MDG 5. The MMR fell from 790 deaths per 100,000 live births in 1990 to 190 in 2013 (figure 1), 4 for an average annual decline of 6 percent. Birth intervals of less than 24 months are considered too short: 20.9 percent of children are born within 24 months of the previous birth. The median number of 5 months since the preceding birth is 36.2 months. The median age at first marriage among women aged 25-49 is 17.5 years and that at first birth among the same cohort is 20.2 years. The share of women age 15- 19 that have begun childbearing is 16.7 percent. The adolescent fertility rate is 73.7 births per 1,000 women 1 age 15–19. Pregnancy Outcomes Complete and timely antenatal care (ANC) is a necessary component for positive pregnancy outcomes. As of 2011, 58.3 percent of women sought ANC from a skilled provider; about 50 percent of women received the recommended four or more ANC visits; 86.4 percent of women had their blood pressure measured (a 5 component in the package of ANC services). Fertility Fertility has been declining. Between 1990 and 2012, Skilled birth attendance (SBA) is critical for reducing the total fertility rate (TFR) fell from 5.2 to 2.4 (figure 2). 1 maternal deaths. SBA increased from 7.4 percent in 1 1991 to 36 percent in 2011 (figure 3). The majority of The contraceptive prevalence rate (CPR) has been births are delivered at home with institutional delivery increasing over the past 20 years. The CPR (any accounting for only 35.3 percent of all births (26 percent in method) increased from 24.1 percent in 1991 to 49.7 public sector facilities, 7.2 percent in private sector 1 percent in 2011 (figure 2). Modern methods are the main facilities, and 2.1 percent in NGO facilities). The most Page 2 HNPGP Knowledge Brief  common reason for not delivering in a health facility was the belief that it was not necessary (62.2 percent). Other reasons include: distance to health facility/no transport (13.5 percent), not customary (9.5 percent), child delivered before reaching facility (8 percent), and cost 5 (4.5 percent). There is also a large gap between wealth quintiles in receiving antenatal care: 91.8 percent of women in the richest quintile received ANC from a qualified professional, but only 33.3 percent of women in the 5 poorest quintile (figure 5). Postnatal care is another important component for maternal health, especially for managing post- delivery complications: 44.5 percent of women sought this type of care from a qualified provider within the 5 recommended first two days of delivery. Of women of reproductive age, 72 percent identified at least one problem in accessing health services Similar disparities are also found in SBA: 72.7 percent when sick. The most common reason was not wanting to of urban women are assisted during delivery by a go alone (60.2 percent), followed by getting money for medically qualified professional but only 32.3 percent of treatment and distance to a facility (about 47 percent rural women (figure 6). 5 5 each) and getting permission (12.6 percent). Equity in Access to Maternal Health Services Inequity in access to maternal health services is a barrier to achieving MDG 5. While utilization of antenatal care has been increasing throughout the years, wide disparities remain. Women in urban areas were more likely to seek antenatal care (87.9 percent) from a qualified professional than their rural counterparts (54.9 5 percent) (figure 4). Page 3 HNPGP Knowledge Brief  Considerable variations in SBA also exist among wealth quintiles. Women in the richest quintile are eight Key Strategies to Improve Maternal times more likely than women in the poorest quintile to and Reproductive Health Outcomes have SBA. Only 10.7 percent of women in the poorest Respond to increasing demands for sexual and quintile receive skilled birth attendance compared with reproductive health from youth and adolescents. 81.5 percent in the richest quintile (figure 7). 5 Nepal has initiated a number of key interventions to expand SRH services to its large youth and adolescent populations to keep girls in school to prevent teenage pregnancy, as well as to improve the nutrition of young mothers, and to provide comprehensive sexuality education in schools. Improve accessibility and quality of RMNCH services at the community and facility levels. The Government of Nepal will work towards strategically mapping birthing centers and providing the facilities with basic and comprehensive EmONC to increase institutional deliveries. Emergency funds for referral services are now available at community level. Expansion is underway of the Birth Preparedness Package, which includes information about FP, nutrition, and supplies of chlorhexidine lotion/ misoprostol. The quality of existing birthing centers needs to be improved in terms of availability of human resources and drugs. Enhancing equitable access to RMNCH services. Nepal has been working to improve access to Nepal has adopted a series of new supply-side services through the Aama Safe Motherhood interventions that include micro-planning exercises for FP program. The program provides free delivery services services, specifically in low contraceptive prevalence rate (CPR) districts, and provision of financial protection in throughout the country, as well as supply- and demand- 6 utilizing health services. In addition, mobilizing private side incentives to increase use of these services. sectors and international NGOs to reach the unreached populations will be necessary. From the demand side, the Nutrition government will strengthen and expand behavior change A BMI less than 18.5 kg/m2 is considered thin or communication campaigns by mobilizing peer educators in undernourished and 18.2 percent of women age 15-49 remote and poor areas, focusing on enhancing males’ are in this category. In addition, 35 percent of women roles as partners to improve FP uptake, and linking safe are anemic; 28.9 percent are mildly anemic; 5.7 percent motherhood incentive programs to FP uptake. are moderately anemic; and 0.3 percent are severely anemic. Nutritional deficiencies are a problem for pregnant and lactating women, and taking micronutrients References: is one way to address the problem: 40.3 percent of 1 World Bank. World Development Indicators 2014: Accessed 19 mothers receive a vitamin A dose in the first two months May 2014 5 2 Nepal:Country Program Snapshot. March 2014, the World Bank after the birth of their last child. 3 UNDP. 2013 Human Development Report Gender Inequality Index 4 WHO, UNICEF, UNFPA and The World Bank. 2014. Trends in Maternal Mortality: 1990 to 2013: World Health Organization 5 Ministry of Health and Population (MOHP) [Nepal], New ERA, and ICF International Inc. 2012. Nepal Demographic and Health Survey 2011. Kathmandu, Nepal: Ministry of Health and Population, New ERA, and ICF International, Calverton, Maryland. 6 Government of Nepal Ministry of Health & Population. “Safer Mother Programme Working Guideline -2065/2009”. Teku, Kathmandu For more information on this topic, go to: www.worldbank.org/health. Page 4