maternal mortality and accidental

312 Pages·2010·10.6 MB·English

NNeeppaall
MMaatteerrnnaall MMoorrttaalliittyy aanndd MMoorrbbiiddiittyy SSttuuddyy
22000088//22000099

Ajit Pradhan
Bal Krishna Suvedi
Sarah Barnett
Sharad Kumar Sharma
Mahesh Puri
Pradeep Poudel
Shovana Rai Chitrakar
Naresh Pratap K.C.
Louise Hulton

Family Health Division
Department of Health Services
Ministry of Health and Population
Government of Nepal
Kathmandu, Nepal

May 2010

TABLE OF CONTENTS

TABLE OF CONTENTS....................................................................................i
TABLES AND FIGURES ..................................................................................v
LIST OF APPENDICES...................................................................................xi
FOREWORD............................................................................................ xiii
ACKNOWLEDGEMENTS................................................................................ xv
ACRONYMS.............................................................................................xvii
EXECUTIVE SUMMARY ................................................................................xxi

CHAPTER 1: INTRODUCTION

1.0 Background and Rationale for Study.............................................................. 1
1.1 Main Findings from the 1998 MMM Study................................................. 1
1.2 Impact of 1998 MMM Study on Policy and Practice...................................... 3
1.3 Study Aim .................................................................................... 4
1.4 Study Objectives............................................................................. 4
1.5 Study Area ................................................................................... 4
1.5.1 District Selection .................................................................. 4
1.5.2 District Characteristics ........................................................... 5
1.6 Study Period ................................................................................. 8

CHAPTER 2: OVERVIEW OF MATERNAL HEALTH IN NEPAL

2.0 Introduction .......................................................................................... 9
2.1 Maternal Health Care Utilisation .......................................................... 9
2.1.1 Antenatal Care (ANC).............................................................10
2.1.2 Intrapartum Care .................................................................12
2.1.3 Postpartum Care ..................................................................14
2.2 Health Service Delivery ...................................................................15
2.3 Fertility ......................................................................................17
2.4 Family Planning ............................................................................19
2.5 Abortion .....................................................................................20
2.6 Maternal Morbidity .........................................................................23
2.7 Maternal Mortality .........................................................................28
2.8 Maternal Health Care Policies.............................................................33
2.9 Maternal Health Interventions in Nepal .................................................36
2.10 Summary of Findings .......................................................................42

CHAPTER 3: METHODOLOGY

3.0 Introduction .........................................................................................43
3.1 Study Components .........................................................................43
3.2 Community Surveillance System .........................................................43
3.3 Maternal Death Review (MDR) ............................................................52
3.4 Emergency Obstetric Care (EOC) Morbidity Monitoring ...............................57
3.5 Facility Assessments........................................................................60
3.6 Staff Competency Assessments ..........................................................63
3.7 Qualitative Components ..................................................................64

CHAPTER 4: ALL CAUSE MORTALITY TO WOMEN OF REPRODUCTIVE AGE (15-49 YRS)

4.0 Introduction .......................................................................................71
4.1 Levels of All Cause Mortality among Women of Reproductive Age ..................71
4.1.1 Comparisons to Other Studies...................................................71
4.2 Cause of Death among Women of Reproductive Age ..................................72
4.2.1 Cause of Death by ICD-10 Chapter .............................................72
Contents i
4.2.2 Comparison of Cause of Death by ICD Chapter with 1998 MMM Study.....74
4.2.3 Leading Individual Causes of Death.............................................75
4.2.4 Comparison of Leading Causes of Death with 1998 MMM Study.............78
4.3 Place of Death for Women Who Died from Non-pregnancy Related Causes .......84
4.4 Characteristics of Women Who Died from Non-pregnancy Related Causes ........85
4.5 Care Received Prior to Death ............................................................87
4.6 Verbal Autopsy Respondent ..............................................................89
4.7 What could have saved the women’s lives?.............................................89
4.7.1 Perspectives of Members of the Community..................................89
4.8 Summary of Findings .......................................................................89
4.9 Discussion....................................................................................90

CHAPTER 5: MATERNAL MORTALITY AND ACCIDENTAL/INCIDENTAL PREGNANCY
RELATED DEATHS

5.0 Introduction .........................................................................................93
5.1 Levels of Mortality..........................................................................93
5.1.1 Levels of Pregnancy Related Mortality.........................................93
5.1.2 Levels of Maternal Mortality.....................................................94
5.1.3 Comparisons to Other Pregnancy Related and Maternal
Mortality Data.....................................................................99
5.1.4 The Opinion of Key Stakeholders Regarding Levels of
Maternal Mortality................................................................99
5.1.5 Levels of Institutional Based Maternal Mortality.............................100
5.2 Causes of Pregnancy Related Mortality ................................................101
5.2.1 Accidental and Incidental Pregnancy Related Deaths ......................102
5.2.2 Maternal Causes of Death ......................................................104
5.2.3 Comparison of Cause of Death Breakdown with 1998 MMM Study ........109
5.2.4 Causes of Institution Based Maternal Deaths ................................111
5.3 Timing of Pregnancy Related Deaths ...................................................114
5.3.1 Timing of Hospital Maternal Deaths ..........................................116
5.4 Place of Death for Women Who Died from Maternal Causes ........................118
5.5 Characteristics of Women Who Died from Maternal Causes ........................119
5.6 Maternal Verbal Autopsy Respondent ..................................................122
5.7 What could have saved the women’s lives?............................................122
5.7.1 Perspectives of Members of the Community ................................122
5.7.2 Perspectives of Providers ......................................................123
5.8 Summary of Findings ......................................................................124
5.9 Discussion...................................................................................126

CHAPTER 6: MATERNAL MORTALITY AND CHRONIC ILLNESS

6.0 Introduction ......................................................................................129
6.1 Major Obstetric Morbidities..............................................................129
6.1.1 Prolonged Labour ................................................................131
6.1.2 Abortion Complications .........................................................133
6.1.3 Haemorrhage .....................................................................135
6.1.4 Retained Placenta................................................................137
6.1.5 Pre-eclampsia.....................................................................140
6.1.6 Eclampsia..........................................................................141
6.1.7 Ectopic Pregnancy ...............................................................142
6.1.8 Puerperal Sepsis..................................................................143
6.1.9 Ruptured Uterus .................................................................144
6.2 Other Obstetric Complications...........................................................145
6.3 Chronic Illness..............................................................................147
6.4 Summary of Findings......................................................................148
6.5 Discussion...................................................................................148

Contents ii
CHAPTER 7: MATERNAL HEALTH CARE SEEKING BEHAVIOUR

7.0 Introduction ........................................................................................151
7.1 Decision Making Process ..................................................................151
7.2 Support from Family, Relatives and Friend............................................153
7.3 Factors Affecting Choice of Care........................................................154
7.4 Antenatal Care.............................................................................154
7.5 Intrapartum Care ..........................................................................157
7.6 Postpartum Care...........................................................................161
7.7 Referral .....................................................................................163
7.8 Changes in Maternal Health Care Seeking Behaviour.................................164
7.9 Summary of Finding .......................................................................165
7.10 Discussion...................................................................................166

CHAPTER 8: QUALITY OF MATERNAL HEALTH CARE

8.0 Introduction ......................................................................................169
8.1 Facilities....................................................................................170
8.1.1 Provision of Services.............................................................170
8.1.2 Referral............................................................................173
8.1.3 Building............................................................................175
8.1.4 Essential Drugs, Equipment and Registers....................................177
8.1.5 Cost of Care.......................................................................180
8.1.6 Health Facility Management Committees.....................................181
8.2 Human Resources..........................................................................181
8.2.1 Availability of Staff..............................................................181
8.2.2 Competency of Staff.............................................................184
8.2.3 Client-provider Relationship....................................................192
8.2.4 Provider’s Perception Regarding Quality of Care............................194
8.3 Evidence Based Practices.................................................................195
8.4 UN Process Indicators.....................................................................198
8.4.1 Proportion of births in Emergency Obstetric Care (EOC) Facilities.......198
8.4.2 Met Need for EOC................................................................198
8.4.3 Caesarean Section Rate ........................................................199
8.4.4 Case Fatality Rates ..............................................................200
8.5 Summary of Findings......................................................................200
8.6 Discussion...................................................................................201

CHAPTER 9: BARRIERS TO MATERNAL HEALTH CARE

9.0 Introduction ......................................................................................203
9.1 Demand Side Barriers .....................................................................203
9.1.1 Lack of Understanding...........................................................203
9.1.2 Culture of Silence................................................................205
9.1.3 Family and Social Restriction...................................................205
9.1.4 Traditional Beliefs and Practices..............................................207
9.1.5 Too Shy or Ashamed to Seek Care.............................................209
9.1.6 Distance to Health Facilities and Lack of Transport ........................209
9.1.7 Cost of Health Care..............................................................211
9.1.8 Demand Side Barriers Contributing to Maternal Deaths....................212
9.2 Supply Side Barriers.......................................................................213
9.2.1 Availability of Services and Referral ..........................................213
9.2.2 Quality of Facilities..............................................................214
9.2.3 Availability of Drugs and Supplies .............................................215
9.2.4 Availability and Ability of Staff ................................................216
9.2.5 Staff Attitude.....................................................................218
9.2.6 Supply Side Barriers Contributing to Maternal Deaths......................219
9.3 Summary of Findings......................................................................220
9.4 Discussion...................................................................................220
Contents iii
CHAPTER 10: THE NEWBORN – LIVE BIRTHS, STILLBIRTHS AND NEONATAL MORTALITY

10.0 Introduction ........................................................................................223
10.1 Live Births...................................................................................223
10.1.1 Age of Mother.....................................................................223
10.1.2 Ethnicity...........................................................................224
10.1.3 Seasonality of Births.............................................................224
10.1.4 National Crude Birth Rate Estimates..........................................225
10.2 Stillbirths....................................................................................226
10.2.1 Stillbirths at EOC Facilities.....................................................226
10.2.2 National Stillbirth Rate Estimates.............................................226
10.3 Neonatal Deaths ...........................................................................226
10.3.1 Neonatal Deaths at EOC Facilities.............................................226
10.3.2 National Neonatal Mortality Rate Estimates .................................226
10.4 Neonatal Outcome.........................................................................227
10.5 Summary of Key Findings.................................................................227
10.6 Discussion ..................................................................................227

REFERENCES...........................................................................................229

ANNEXES...............................................................................................241
Contents iv
TABLE AND FIGURES

CHAPTER 1: INTRODUCTION

Table 1.1: Selected Districts by Topography and Region ................................................ 4
Table 1.2: Population for the Selected Districts.......................................................... 5
Table 1.3: Human Development Index Ranking of Study Districts...................................... 6
Table 1.4: Administrative Units in Study Districts........................................................ 7
Table 1.5: Number and Type of Health Facilities in Study Districts.................................... 8

Figure 1.1: Map Showing the Location of the Eight Study Districts...................................... 5
Figure 1.2: Chart Showing the Distribution of Major Ethnic/Caste Groups in the
Study Districts..................................................................................... 6

CHAPTER 2: OVERVIEW OF MATERNAL HEALTH IN NEPAL

Table 2.1: Basic, Comprehensive EOC Facilities and Birthing Centers in Nepal: 2008/09..........14
Table 2.2: Number of Providers Trained, Site Listed and CAC Cases in Nepal:
2004/05 – 2008/09...............................................................................23
Table 2.3: Percentage Distribution of Direct Obstetric Morbidities: Selected
Districts, Nepal: 1997/98 to 2008/09.........................................................24
Table 2.4: Prevalence of Prolapsed Uterus...............................................................27
Table 2.5: Maternal Mortality Data for Nepal, WHO and DHS 1990-2005.............................31
Table 2.6: Nepal HMIS Data on Maternal Mortality 1996-2003 .........................................32
Table 2.7: Maternal Health Policies in Nepal.............................................................34
Table 2.8: Maternal Health Targets and their Status by 2008..........................................36
Table 2.9: Maternal Health Interventions in Nepal......................................................37

Figure 2.1: Antenatal Care Utilisation 1996-2006.........................................................11
Figure 2.2: Live Births Delivered in a Health Facility and Assisted by SBA 1996-2006...............13
Figure 2.3: The Total Fertility Rate 1996-2006............................................................17
Figure 2.4: Use of Contraception by Currently Married Women........................................19
Figure 2.5: Maternal Mortality Ratio (MMR) Estimates in Nepal (1996-2005) with Confidence
Intervals/Uncertainty Bounds..................................................................32

CHAPTER 3: METHODOLOGY

Table 3.1: Persons Trained for Verbal Autopsy by District..............................................49
Table 3.2: Sampling Frame for Intensive Verification...................................................51
Table 3.3: Location of MPDR/MDR..........................................................................56
Table 3.4: Training for Hospital Based Maternal Death Review........................................56
Table 3.5: District, Basic and Comprehensive EOC Facilities in the EOC Monitoring System......59
Table 3.6: Training for EOC Monitoring....................................................................59
Table 3.7: Location of Facility and Staff Assessments...................................................62
Table 3.8: Ethnicity Covered in the FGD by District.....................................................67

Figure 3.1: Study Components...............................................................................43
Figure 3.2: The Community Verbal Autopsy Process .....................................................46
Figure 3.3: The MDR Process.................................................................................55

CHAPTER 4: ALL CAUSE MORTALITY TO WOMEN OF REPRODUCTIVE AGE (15-49 YRS)

Table 4.1: Levels of All Cause Mortality among Women of Reproductive Age.......................71
Table 4.2: Comparison of Death Rate in 1998 and 2008/09 MMMS ....................................72
Table 4.3: Cause of Death, by ICD-10 Chapter, for All Deaths to Women of
Reproductive Age, by District..................................................................73
Table and Figures v
Table 4.4: Comparison of Cause of Death, by ICD-10 Chapter, for All Deaths to
Women of Reproductive Age between MMMS 1998 and MMMS 2008/09..................74
Table 4.5: Top Twenty Individual Causes of Death, for All Deaths to Women of
Reproductive Age................................................................................75
Table 4.6: Top Ten Individual Causes of Death, for All Deaths to Women of Reproductive
Age, by District ..................................................................................77
Table 4.7: Comparison of Top 5 Individual Causes of Death for All Deaths to Women of
Reproductive Age between MMMS 1998 and MMMS 2008/09...............................78
Table 4.8: Characteristics of Women Who Died from Suicide..........................................79
Table 4.9: Underlying Factors for Suicide Related Deaths..............................................81
Table 4.10: Methods Used for Suicide Related Deaths....................................................82
Table 4.11: Place of Death for Women Who Died from Non-pregnancy Related
Causes by District................................................................................84
Table 4.12: Age Specific Death Rates for MMMS 2008/9, 2001 Census and 2006 NDHS ..............85
Table 4.13: Demographic Characteristics of Women Who Died from Non-pregnancy
Related Causes, by District.....................................................................86
Table 4.14: Socio-economic Characteristics of Women Who Died from Non-pregnancy
Related Causes by District......................................................................86
Table 4.15: Care Received by Women Who Died from Non-pregnancy Related
Causes by District................................................................................87
Table 4.16: Reason for Not Receiving Care before Death by District...................................88
Table 4.17: Treatments Recommended and Received Prior to Death by Women
Who Died from Non-Pregnancy Related Causes by District................................89

Figure 4.1: Comparison of Cause of Death, by ICD-10 Chapter, for All Deaths to
Women of Reproductive Age between MMMS 1998 and MMMS 2008/09..................75
Figure 4.2: Place of Death for Women Who Died from Non-pregnancy Related Causes.............84
Figure 4.3: Treatments Recommended and Received Prior to Death by Women
Who Died from Non-pregnancy Related Causes.............................................88

CHAPTER 5: MATERNAL MORTALITY AND ACCIDENTAL/INCIDENTAL PREGNANCY
RELATED DEATHS

Table 5.1: Levels of Pregnancy Related Mortality by District..........................................94
Table 5.2: Levels of Maternal Mortality by District......................................................94
Table 5.3: Proportion of Maternal Deaths by Age-group................................................95
Table 5.4: Estimates of Maternal Mortality from Other Data Sources.................................99
Table 5.5: Hospital Based Maternal Mortality by District..............................................100
Table 5.6: Resident Status of Maternal Deaths in Hospitals by District..............................101
Table 5.7: Maternal Mortality at EOC Facilities by District............................................101
Table 5.8: Pregnancy Related Deaths by Accidental/Incidental, Maternal or
Unknown Cause, by District...................................................................102
Table 5.9: Accidental and Incidental Causes of Pregnancy Related Deaths.........................102
Table 5.10: Proportion of Direct and Indirect Maternal Deaths by District...........................104
Table 5.11: Direct Causes of Maternal Deaths by District...............................................105
Table 5.12: Indirect Causes of Maternal Deaths by District.............................................108
Table 5.13: Comparison of Pregnancy Related Deaths from 1998 and 2008/09 Maternal
Mortality and Morbidity Studies ..............................................................110
Table 5.14: Comparison of Causes of Maternal Deaths from 1998 and 2008/09 MMM Studies .....111
Table 5.15: Proportion of Direct and Indirect Maternal Deaths in Institutions by District..........112
Table 5.16: Proportion of Direct and Indirect Institutional Maternal Deaths to Women
Who Were Usual Residents in the Study Area...............................................112
Table 5.17: Causes of Hospital Based Maternal Deaths..................................................113
Table 5.18: Timing of Pregnancy Related Deaths by District...........................................114
Table 5.19: Timing of Maternal Death by Cause of Death...............................................116
Table 5.20: Timing of Hospital Maternal Deaths..........................................................117
Table 5.21: Timing of Hospital Based Maternal Deaths by Cause of Death...........................117
Table 5.22: Status on Admission for Hospital Maternal Deaths.........................................118
Table 5.23: Levels of MMR by Age-group and Ethnicity..................................................119
Table and Figures vi