The Nepal Government with the support of donors, including the Australian Government, has made significant progress in keeping children alive and preventing mothers dying in childbirth – despite a decade-long armed conflict, political instability, poverty, inequality and challenging terrain.
Holistic approach to health
Maternal deaths fell from 539 per 100,000 live births in 1991 to 170 in 2011. Similarly, the under-five mortality rate is 75 per 1000 live births for the poorest 20% and 36 per 1000 live births for the richest 20%. The under-five mortality rate declined from 118 to 54 per 1000 live births.
The government of Nepal has coordinated a country-wide strategy over two decades. There has been a sustained investment in a system of health care with strong community-based services being delivered through trained female community health volunteers. Nepal has doubled health spending and concentrated on the poorest areas. Experienced health ministry officials have used data about the causes of maternal death and their knowledge of the barriers to accessing services in remote areas to formulate and advocate for change.
Birthing centres were built, staffed with trained birth attendants 24 hours a day and supplied with medicines. Safe blood supplies were made available for emergencies. Almost 50,000 female community health volunteers have visited women in their villages and educated them about preventative health, safer birthing practices, family planning, nutrition and hygiene.
Women are now more likely to deliver their babies with a skilled birth attendant (36 per cent in 2011 compared to 19 per cent in 2006) and to have babies immunised (96 per cent in 2011 compared to 82 per cent in 2010). Increased access to family planning means Nepali women now have an average of 2.6 children (down from 6 children in the 1980s).
The Aama Surakchhya Programme provides financial incentives to mothers who deliver at a health facility, with a free service and covering costs of travel. Women who attend four antenatal care visits are also paid.
Improving the lives of women generally depends on the cultural expectations of their role.
Sociocultural norms and taboos continue to prevent women of different ethnic groups or living in remote areas from gaining an education, earning a living and seeking medical treatment. The cultural tradition of chaupaudi, which isolates menstruating women and mothers who have just given birth because they are 'impure', is still practised in the mid- and far-western regions, despite being banned by the Supreme Court in 2004.
Education is a key factor for poverty reduction and accessing available health services. Scholarships, school feeding and mother-tongue teaching have increased the number of girls and children from the disadvantaged Dalit and Janjaati groups attending school. An increase in the education level of mothers has led to a large increase in the number of expectant mothers seeking health care.
Water and sanitation
Improvements in access to water and sanitation support health and nutrition and reduce poverty.
Programs have increased access to safe drinking water to less than a 20-minute walk and increased access to basic sanitation so that many communities have been declared 'open defecation free'. This means women are freed to care for family and earn an income, and girls are more able to attend school. Improved knowledge of hygiene practices (hand washing with soap and water) has led to decreases in water borne-diseases.
Poverty is a factor associated with low access to health care. The Micro-enterprise Development Program facilitates entrepreneurship with training and access to finance. The program predominantly supports women, who have used grants to start small businesses making clothing and jewellery, weaving, farming and cooking snacks. They have lifted themselves out of poverty and gained self-confidence and respect in their communities.
Poverty has dropped from 42% of the population in 1996 to 25% in 2011. Women are now more likely to have paid work and have greater wage equality, but they still have low access to property ownership, financial credit and political power.
Although Nepal has made strong progress, not all groups have benefitted equally, and the maternal mortality rate is still high in comparison to many developed countries.
Inequity based on wealth, setting (rural/urban), region, caste and ethnicity has contributed to great differences in maternal health and child mortality throughout Nepal. For instance, the percentage of deliveries assisted by skilled birth attendants is 10.7% for the poorest 20% of the population, and 81.5% for the richest 20%. Similarly, the under-five mortality rate is 75 per 1000 live births for the poorest 20% and 36 per 1000 for the richest 20%. The under-five mortality rate is three times higher for the Muslim minority than for the high-caste Newaris.
Slowing economic growth and political uncertainty will be a challenge to sustaining the investment in women and children's health and improving the reach to rural areas and all cultural groups.
Overseas Development Institute (UK), Nepal's Story: Understanding improvements in maternal health
World Bank, Maternal and child health video
Australian Aid, Enterprising Women: Nepal's micro-entrepreneurs in their own words (nine short films)