An analysis of factors linked to the decline in maternal mortality in Nepal

Abstract

Nepal experienced a steep decline in maternal mortality between 1996 and 2006, which had again dropped by 2010. The aim of this study was to investigate any trends in factors that may be responsible for this decline. The study was based on a secondary data analysis of maternity care services and socio-demographic variables extracted from the Nepal Demographic Health Surveys (1996, 2001, 2006 and 2011). Complex sample analysis was performed to determine the trends in these variables across the four surveys. Univariate logistic regression was performed for selected maternity care service variables to calculate the average change in odds ratio for each survey. Multivariate logistic regression was performed to determine the trends in the health service uptake adjusting for socio-demographic variables. There were major demographic and socio-economic changes observed between 1996 and 2011: notably fewer women delivering at 'high risk' ages, decreased fertility, higher education levels and migration to urban areas. Significant trends were observed for improved uptake of all maternity care services. The largest increase was observed in health facility delivery (odds ratio = 2.21; 95% confidence interval = 1.92, 2.34) and women making four or more antenatal visits (odds ratio = 2.24; 95% confidence interval = 2.03, 2.47). After adjusting for all socio-demographic factors, the trends were still significant but disparities become more pronounced at the extremes of the socio-economic spectrum. The odds ratios for each maternity care service examined decreased slightly after adjusting for education, indicating that improved levels of education could partly explain these trends. The improved utilisation of maternity care services seems essential to the decline in maternal mortality in Nepal. These findings have implications for policy planning in terms of government resources for maternity care services and the education sector.

Figure 1. Trends in delivery care between 1996 and 2011.

The percentage of the women delivering in health facilities increased slightly between 1996 and 2001, and nearly doubled in 2006. In 2006, 19.4% of respondents delivered in a health facility, which increased dramatically to 38.5% in 2011. The assistance during delivery by skilled birth attendants increased marginally from 9.1% to 20.6% between 1996 and 2006. However, it rose significantly to 39.1% in 2011. Women reporting Caesarean section delivery increased slightly from 1% in 1996 to 1.1% in 2001. It then increased drastically to 5.2% in 2011.

Figure 2. Trends in antenatal care between 1996 and 2011.

Antenatal care (ANC) from skilled professionals nearly doubled over time. In 1996 only 25.2% of the pregnant women received ANC from a skilled professional, but increased to 58.3% in 2011. The proportion of women with four or more ANC visits increased significantly from 9.2% to 50.1% between 1996 and 2011. The results from the surveys indicated that an antenatal check-up within the first trimester nearly doubled from 30.5% in 1996 to 58.5% in 2011.