Hospital Birth in Nepal

To reduce high rate of maternal mortality in developing nations like Nepal expectant mothers are encouraged to have births assisted by a midwife or a skilled birth attendant at health care facilities. However, in Nepal there is no separate cadre of midwife yet and childbirth in health-care facilities is very limited to urban areas and mainly provides a medical model of maternity care by both public and private sectors. In the public sector this care is free of charge as per the government of Nepal’s Aama Surakshya Programme, which has three components: free institutional delivery care, the Safe Delivery Incentive Programme, and incentive to women who completed four antenatal care visits and delivered their babies at health institutions. According to this programme women get free of charge delivery care, and depending upon the ecological regions of the country a cash payment of NPR.1,500 ($20) in mountain areas, NPR.1,000 ($13) in hill areas and NPR.500 ($7) in the tarai (plain area) after giving birth at a facility is provided to all women. Such a scheme has been introduced by the government of Nepal as per the commitment in achieving millennium development goals 4 i.e. reducing child mortality and 5 i.e. improving maternal health, and the right of every woman to access good standard free of charge reproductive health as outlined in 2007 Nepal’s interim constitution.

In the private sector, however, expecting mothers have to pay in order to access maternity care service. Some private hospitals, which have introduced Aama Surakshya Programme, signing the memorandum of understanding with the government of Nepal provides free institutional delivery care (normal, complicated and cesarean section) for every woman. Despite the attractive free maternity service scheme, a woman in childbirth and 11 newborn babies die unnecessarily every four hours in Nepal (NDHS 2011). The raw data from the Department of Health Services Annual Report of Fiscal Year 2009/2010 shows that 564 maternal death, 2795 neonatal death and 3,831 stillbirths had occurred in a year. It highlights that relatively maternal and neonatal deaths were much higher in the mid-western and central regions of Nepal. Similarly, Nepal Demographic Health Survey 2011 reports that perinatal mortality rate of Nepal is 37 per 1,000 pregnancies and is higher among young mothers (below age 20), among births that occur less than 15 months after the previous birth, in rural and mid-western region. One of the possible reasons for such a high death of mothers and newborns may be due to an absence of professional midwifery practice in the country. On the absence of professional midwife, nurses are the key healthcare providers for maternity care and since 2007 they have been provided two months additional in-service skilled birth attendants to sharpen midwifery skills. However, there are an insufficient number of skilled birth attendants (GoN 2010).

The government of Nepal has set the target to increase in the percentage of deliveries assisted by a skilled birth attendant (nurse and doctor) to 60% and the percentage of deliveries taking place in a health facility increased to 40% by 2015. However, the recent Nepal Demographic Health Survey 2011 shows that only 36% of births are assisted by skilled healthcare providers, of this more than half (19%) of the births are assisted by nurses and another half by doctors (17%). The same survey demonstrates that only 35% childbirth takes place in a health facility and majority (26%) of births take place in government health facilities. In a private sector only negligible (9%) percent of women seek such services. The vast majority (63%) of women give birth at home without medical assistance and mainly their births are assist by relatives (40%) followed by traditional birth attendants (11%) and other healthcare professionals who don't have midwifery skills. This is because of entrenched cultural/religious belief that birth is a normal phenomenon thus seeking medical assistance is not required and Nepalese women tend to be shyer and more easily embarrassed exposing their bodies and sharing their concern to others (Mullay 2006; Manandhar 2002).

In Nepal, there is very limited Comprehensive Emergency Obstetric Care (CEOC) includes surgery (caesarean section), anaesthesia and blood transfusion along with Basic Emergency Obstetric Care (BEOC) that covers management of pregnancy complications by assisted vaginal delivery (vacuum or forceps), manual removal of placenta, removal of retained products of abortion (manual vacuum aspiration), and administration of parental drugs (for postpartum haemorrhage, infection and pre-eclampsia/eclampsia), resuscitation of newborn and referral. Out of total 75 districts in the country, there are only 94 CEOC sites in 45 districts (GoN 2010). Of these 45 districts with CEOC facility, as of 2010 only 33 are functional and 12 are nonfunctional mainly due to lack of human resource. However, in rural areas BEOC services is available at 105 sites (47 hospitals and 58 Primary Health Care Centers that has three maternity beds). Twenty four hour delivery service is available at 148 Primary Health Care Centers, 406 health posts and 137 sub-health posts in rural settings. The government of Nepal including donor agencies also called these sites, as birthing centers mainly because Auxiliary Nurse-Midwife and Staff Nurses independently provide childbirth services and services are available 24 hours.

There is a huge disparity in the accessibility and availability of CEOC in Nepal. At present, only 5% of births are delivered by caesarean section in Nepal (NDHS 2011). Nevertheless, delivery by caesarean section is highest among births by urban women (15%), births to mothers in the highest wealth quintile (14%), highly educated mothers (13%), and first births (7%). Among births delivered by caesarean section, 12% were planned, while the rest was carried out due to complications at delivery. In the private sector health facilities, majority of women births take place via caesarean section. It ranges from 40% to almost 90%. This has to be investigated thoroughly since majority of women in rural areas are not accessing CEOC and in urban areas women encountering obstetric violence cutting unnecessary while giving a birth.

Since the majority of women still give birth at home, the aim is to ensure that normal delivery care and referral services are available at community level through home visits, outreach clinics, and health posts/ sub health posts with 24 hours birthing centers able to manage normal deliveries. Professional birth assistants and more humanized birth care that involves respecting women’s decisions and preferences during childbirth are important vehicles for providing a safe and comforting birth experience for women (Behruzi et al. 2010). Therefore, there is urgency in improving the availability of affordable services of competent, confident, committed and compassion skilled birth attendants service providers in underserved communities in saving the lives of expectant mothers and babies by providing humanized maternity care services that allow women control of the process and provide different types of maternity care options.

Reference
Government of Nepal (GoN) 2010, Annual Report FY 2009/2010, Department of Health Services, Ministry of Health and Population, Ramshahpath, Kathmandu, Nepal.
Behruzi, R., Hatem, M., Fraser, W., Goulet, L., Li, M., Misago, G., 2010. Facilitators and barriers in the humanization of childbirth practice in Japan. BMC Pregnancy Childbirth 10:25.
Manandhar, M., 2000. Ethnographic prospective on obstetric health issues in Nepal. A literature review. Nepal Safer Motherhood Project, Department of Health Services, Ministry of Health and Poplation; His Majesty’s Government of Nepal., 176/96 DFID.
Ministry of Health and Population (MoHP) [Nepal], New Era & Macro International Inc 2012. Nepal Demographic Health Survey 2011. Kathmandu, Nepal: Minsitry of Health and Population, New ERA and Macro International Inc.
Mullay, BC., 2006. Barriers to and attitude towards promoting husbands’ involovment in maternal health in Kathmandu, Nepal. Social Science Medicine, 62 (11): 2798-809.