EXECUTIVE SUMMARY

Introduction

The Nepal Multiple Indicator Surveillance (NMIS) began with a multisectoral baseline survey in early 1995. The NMIS was designed from the beginning as an-ongoing monitoring scheme to produce information useful for planning at national, district, community and household levels, rather than as a one-off survey.

Nepal, as a signatory to the 1989 UN Convention on the Rights of the Child, is committed to report on its implementation. Among other things, the NMIS serves as an important means of monitoring violations of children's rights in Nepal. It has also assisted HMG Nepal to monitor progress towards the 1990s Goals and Mid-decade Goals agreed at the World Summit for Children as embodied in its National Plan of Action for Children and Development for the 1990s.

The NMIS process comprises repeated cycles of data collection, analysis, interpretation, and communication of results to stimulate action. Each cycle focuses on a priority issue or set of issues. Cycle 2 focused on Primary Education in the spring and summer of 1995; cycle 3 on Diarrhoea, Water and Sanitation in the first half of 1996; and cycle 4 on early child feeding, nutrition and development in late 1996.

This fifth cycle of the NMIS focuses on care for women during pregnancy and delivery and the relationship between this and the outcome of pregnancy, in terms of estimates of low birth weight and survival of the baby.
It is timely in view of the recent publication of the National Maternity Care Guidelines for Nepal. It is intended to provide information on the current situation in relation to the targets set in the guidelines and some insights about what might help to improve matters, for use by service planners and providers at national and local levels. No attempt was made to estimate maternal mortality. Estimates of maternal mortality in Nepal are available from other sources.

According to the 1996 Nepal Family Health Survey, the maternal mortality rate for the 1990-1996 period is 539 deaths per 100,000 live births (or alternatively 5 deaths per 1,000 live births). The 1991 Nepal Family Health Survey estimated the MMR as very similar: 515 deaths per 100,000 live births. However, according to the State of the Worlds Children of 1998 published by UNICEF, the MMR for Nepal is 1,500/100,000 live births. It is difficult to draw any conclusion regarding the trend of

MMR in Nepal, but according to the UNICEF figures it remains as one of the highest in south Asia.

Existing figures for maternity care coverage are estimates from facility-based data and expected numbers of pregnancies. NMIS cycle 5 provides direct estimates to allow comparison with the standards set in the National Maternity Care Guidelines.

Methods

The NMIS employs Sentinel Community Surveillance (SCS). Features of this method include: the focus of each cycle on a small group of issues; the combination of quantitative and qualitative data from the same communities in a mesoanalysis; data analysis and risk analysis to produce results in a form useful for planning; revisiting of the same sites, making estimation of impact of interventions easier.

The sites in NMIS cycle 5 are the same as for the first four NMIS cycles, selected by a multistage random sampling method. The sites are representative of the country, of the five development regions, of the three ecological zones, of the 15 eco-development regions, and of urban and rural situations. Representation of the 15 eco-development regions is among the rural sites only; the urban sites are stratified separately and are not intended to be part of the representation of the different eco-development regions. This reflects the high proportion of the population living in rural communities (nearly 90%).

A total of 18,996 households were visited in the 144 sites. Information was available for 18,653 households (99%). Only 1% households refused the interview. The total population in the households interviewed is 106,160 people. More detailed information was collected from ever-married women aged 15-49 years: a total of 19,557 women. They reported on their last pregnancy and data on a total of 17,609 pregnancies were collected.

Household information was collected from:
  • 18,653 households
  • 106,160 people
  • 19,557 ever-married women 15-49 years
  • 17,609 pregnancies

The instruments used in cycle 5 include a household questionnaire, focus group guides, key informant and Traditional Birth Attendant (TBA) interviews, and a health facility review/interview. They are reproduced in Annex 2.

Instruments used in NMIS cycle 5:
  • Household questionnaire
  • Health facility interview schedule
  • Hey informant and TBA interviews
  • Focus group guides

The sample sizes in districts are not proportional to the populations of the Districts; weights calculated to take this into account were applied when producing national indicators.

 

Results and risk analysis

Antenatal care and practices

Information was given about a total of 17,609 pregnancies. This includes 260 women pregnant at the time of the household questionnaire. The mean number of pregnancies the women had previously is 3.7 (s.d. 6.5), median 3.0. The mean time since the last pregnancy was 5.0 years, (s.d. 4.9 years). For 55% the last pregnancy was 3 years ago or less; for 67% it was 5 years or less ago; and for 85% it was 10 years or less ago. The mean age at the time of the last pregnancy was 26 years (s.d 6.3 years), median 26 years.

Three quarters (76%) of Nepali women giving birth in the last 5 years receive no formal antenatal care

Fewer than one in ten women receive the four antenatal care visits that are considered to be desirable in the National Maternity Care Guidelines. And among those who had any antenatal care visits, only 43% went for their first antenatal visit within the first three months of pregnancy. The commonest reasons given for not having antenatal care were to do with not perceiving a need for routine antenatal care, which has no part in local traditions, and which women are unaware of as a service.

A quarter (25%) of ever-married women of child bearing age (15-49 years) in the survey are literate by self report. One in three (34%) of these women admit to smoking during their most recent pregnancy. Nearly all the women in the survey (95%) reported that they worked for 8 or 9 months of their last pregnancy. And less than one in ten (8%) report having a health problem during their last pregnancy.

A number of variables individually increase the risk of women not attending for antenatal care.

The great majority of women who had any antenatal care visits went to government health facilities: over half (57%) reported going to the district hospital; 19% went to a health post and 13% to private clinics. As many as 50% of the women who reported having antenatal care said they were seen by a doctor. The mean payment reported per visit was 223 Rs (median 60 Rs).

Only one in ten (10%) women receive iron/folate supplements during pregnancy, and only 2% take them for more than three months. Half the women (50%) giving birth in the last 5 years received at least one dose of tetanus toxoid during their last pregnancy. Of women who attended for antenatal care, only a quarter (25%) recalled a discussion about place of delivery and only a quarter (25%) reported being advised about breast feeding. Most of them (59%) reported being "somewhat satisfied" with the care they received, with 5% being "not at all satisfied" and 36% being "very satisfied". Most (73%) women were not able to say what was the problem with antenatal services, but problems mentioned included poor facilities, long waiting times, lack of medicines and absence of staff.

Only a minority of women could give suggestions for services to improve antenatal care. They mentioned more health posts and more, better trained staff. In the focus groups, women mentioned the need for more female doctors. Suggestions for what communities could do included reducing the work load of women and providing transport and urgent assistance when needed. Health workers generally suggested that more of everything would help them to provide a better service.

 

Delivery care

Nine out of ten (91%) women deliver their babies at home. A number of variables are related to the place of delivery:

Less than one in ten deliveries (6%) within the last 5 years is attended by a trained TBA or other trained worker. About half (54%) of families incurred some expenditure for the woman's last delivery. The median total cost is 400 Rs, and is higher if there are problems during labour and higher in urban locations.

Very few women (3%) reported they used a HDK for their last delivery. Even for deliveries in the last 3 years, since HDKs came onto the market, the use is only 4%. The likelihood of using an HDK for a home delivery is increased if the woman is literate, if she has attended for antenatal care and if the birth is attended by a trained TBA or other trained health worker.

Approaching two thirds (59%)of women reported that their last baby's cord was cut with a clean instrument, mostly a new blade or a boiled old blade. The chances of the cord being cut with a clean instrument are increased if the woman is literate, if she is less than 36 years old, and if the delivery is within the last 5 years.

About a third (37%) women reported that nothing was applied to the cord, 6% treated it with antiseptic and 57% with ash, cowdung or oil. If the cord is cut with a clean instrument, and either antiseptic or nothing is applied, the cord is regarded to have been treated safely. On the other hand, if the cord is cut cleanly but later on the stump is covered with unclean materials, the cord is regarded to have been treated unsafely. Using these criteria, 52% women reported the cord was treated safely.

The median reported duration of labour is 4 hours. A fifth (19%) of reported labours lasted more than 12 hours. About one in 25 (4%) women reported a health problem during their last labour. A woman with health problems during pregnancy is more than 5 times more likely to develop problems during labour.

Women with health problems during labour are three and a half times more likely to deliver in a health facility. Nevertheless, even among those reporting a health problem during labour, 71% still deliver at home. For three quarters of the women who had health problems during labour, their families sought help. A third sought help from a hospital, nearly a fifth from a private doctor or clinic and one in ten from another government health facility. Reasons given for not seeking help included that it was not thought necessary (44%), that the help was too far away (35%) and that it was too expensive (16%).

One in ten (10%) mothers reported health problems for themselves or for their babies after delivery. Common problems include: fever of mother or baby, retained placenta, excessive bleeding, and weakness of mother or baby. Help was sought from the same places as for problems during labour.

 

Delivery outcome

a. Birth weight

Birth weight was estimated by mothers as very small, small, normal or big. One in five (19%) of most recent births is reported by the mother to be small or very small. A higher proportion of babies born within the last ten years are reported to be small or very small. This might be due to better recall but certainly suggests no reduction in the proportion of low birth weight babies in recent years.

A number of variables increase the risk of a low birth weight baby:

b. Survival of baby

Overall, 2.3% of babies were reported to have been still born or to have died soon after birth. A number of variables increase the risk of the baby dying before or soon after birth:

Analysis for action

In this section, the combined effects of variables amenable to change upon the outcomes of interest are examined. The potential benefits that could be achieved by interventions to modify the factors related to adverse outcomes are estimated, with the intention of providing information to assist planners at all levels in their decision-making processes.

The effects of variables in combination are examined using multiple logistic regression. Step-down from a saturated model is used to find the best-fitting, most parsimonious model.

Variables related to the likelihood of attending for antenatal care that remain in the final logistic regression model are: literacy of mother; area of residence; working for more than 7 months of pregnancy; smoking in pregnancy; literacy of the household head; more than 4 pregnancies; and support from the family.

Variables increasing the risk of low birth weight babies in the final model are: illiteracy of the mother; health problems in pregnancy; smoking in pregnancy; illiteracy of the household head; lack of support from the family; and living in rural area.

Variables increasing the risk of still birth or death soon after birth in the final model are: health problems in labour; lack of satisfaction with care during labour; low birth weight; living in rural area; illiteracy of the mother; bhealth problems in pregnancy; and cutting the cord with a non-clean instrument.

The possible benefits to be gained from different interventions for each outcome are shown in Tables 99, 100 and 101 (reproduced below for convenience). The priority interventions, having potential benefits for more than one outcome, are: improving literacy of mothers, identifying and managing health problems in pregnancy, preventing smoking in pregnancy, improving services for rural areas, improving literacy of household heads, and encouraging family support for pregnant women.

Table 99. Possible benefits of different interventions to increase the proportion of women attending for antenatal care

 Intervention

Potential individual benefit (from OR)

Potential population benefit (from RD)

Proptn of population who could benefit

Relative cost of possible interventions

Ensure literacy of women of child bearing age

Double the chance of ANC

18% more women to attend ANC

Three quarters of pregnant women

Moderate

Improve access and knowledge in rural areas

Double the chance of ANC

17% more women to attend ANC

Nine out of ten pregnant women

High

Discourage women from working up to end of pregnancy

Nearly double the chance of ANC

14% more women to attend ANC

Nine out of ten pregnant women

Low

Stop-smoking campaign for pregnant women

Increase chance of ANC by half

8% more women to attend ANC

About a third of pregnant women

Low/moderate

Ensure adult literacy (for household head)

Increase chance of ANC by a fifth

5% more women to attend ANC

About half of pregnant women

Moderate

Encourage limit of 4 pregnancies

Increase chance of ANC by a fifth

4% more women to attend ANC

Over a third of pregnant women

Low/moderate

Ensure family support for pregnant women

Increase chance of ANC by 10%

3% more women to attend ANC

About one out of ten women

Low

Note: The proportion of the population who could benefit is that proportion not currently having the favourable level of the variable. For example, the proportion of pregnant women currently illiterate.

Table 100. Possible benefits of different interventions to decrease the risk of low birth weight babies

Intervention

Potential individual benefit (from OR)

Potential population benefit (from RD)

Proptn of population who could benefit

Relative cost of possible interventions

Ensure literacy of women of child bearing age

Decrease risk of LBW by a quarter

4% less LBW babies

Three quarters of pregnant women

Moderate

Identify and manage pregnancy problems

Decrease risk of LBW by a quarter

4% less LBW babies

A tenth of pregnant women

High

Stop-smoking campaign for pregnant women

Decrease risk of LBW by 13%

2% less LBW babies

About a third of pregnant women

Low/moderate

Ensure adult literacy (for household head)

Reduce risk of LBW by 10%

2% less LBW babies

About half of pregnant women

Moderate

Improve access and knowledge in rural areas

Reduce risk of LBW by 8%

1% less LBW babies

Nine out of ten pregnant women

High

Ensure family support for pregnant women

Reduce risk of LBW by 8%

1% less LBW babies

About one out of ten women

Low

Note: The proportion of the population who could benefit is that proportion not currently having the favourable level of the variable.

 

Table 101. Possible benefits of different interventions to reduce risk of still birth and death soon after birth

Intervention

Potential individual benefit (from OR)

Potential population benefit (from RD)

Proportion of population who could benefit

Relative cost of possible interventions

Identify and manage labour problems

Reduce risk of death twofold

3% less babies dying

One in twenty pregnant women

High

Improve quality of delivery care

Reduce risk of death twofold

3% less babies dying

One in twenty women

High

Actions to prevent LBW (Table 100)

Reduce risk of death by two thirds

2% less babies dying

A fifth of pregnant women

High

Improve access and knowledge in rural areas

Reduce risk of death by more than half

2% less babies dying

Nine out of ten pregnant women

High

Ensure literacy of women of child bearing age

Reduce risk of death by 40%

1% less babies dying

Three quarters of pregnant women

Moderate

Identify and manage pregnancy problems

Reduce risk of death by a fifth

1% less babies dying

A tenth of pregnant women

High

Ensure cord cut with clean instrument

Reduce risk of death by a fifth

1% less babies dying

Four out of ten pregnant women

Low

Note: The proportion of the population who could benefit is that proportion not currently having the favourable level of the variable.

Priority interventions

Several interventions will have effects on more than one of the outcomes in the survey. They are shown in Table 102.

Table 102. Interventions affecting several outcomes

Intervention

Outcomes

 

ANC

LBW

Death of baby

Reduce illiteracy of pregnant women

+

+

+

Manage pregnancy problems

 

+

+

Prevent smoking in pregnancy

+

+

 

Improve rural antenatal and delivery services

+

+

+

Reduce illiteracy of households heads

+

+

 

Ensure more family support in pregnancy

+

+

 

The multiple potential benefits of these interventions suggest that they should be given some priority.

Another way of deciding the priority of different interventions is on the basis of the magnitude of the potential benefits (either for individual women or for the whole population of pregnant women) in relation to their costs. The magnitude of benefits of different interventions is indicated in Tables 99, 100 and 101, together with an indication of their likely relative cost to the government and other service providers. Clearly, many of the interventions, to be successful, will require actions at several levels. They will need support from central government, and action at local level. Local actions will include those from NGOs as well as from government bodies.


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