Nepal Multiple Indicator Surveillance
The Nepal Multiple Indicator Surveillance (NMIS) began in 1994, with a first cycle in early 1995 on Health and Nutrition1 that covered a number of indicators necessary to assess progress toward development goals. The NMIS was designed as an-ongoing monitoring scheme rather than a one-off survey.
In 1989 the United Nations adopted the Convention on the Rights of the Child and it came into force in 1990. Nepal, as a signatory to this convention, is required to submit periodic reports on its implementation2. Nepal is also a signatory to the Convention to End Discrimination Against Women (CEDAW)3. Among other things, the NMIS serves as an important means of monitoring violations of the rights of children
and women in Nepal. It has also assisted HMG Nepal to monitor progress against the 1990s Goals and Mid-decade Goals agreed at the World Summit for Children (WSC) as embodied in its National Plan of Action (NPA) for Children and Development for the 1990s4. These two purposes of the NMIS scheme are closely linked: the failure to meet children's needs as specified in the WSC and the Nepal NPA is, in fact, a violation of their rights5. The achievement of WSC goals is a necessary but not sufficient condition for the realisation of corresponding rights6. International research is on-going on defining the best indicators for childrens rights7. But some are clearly already included in the NPA goals.The NMIS process comprises repeated cycles of data collection, analysis, interpretation, and communication of results to stimulate action. Each cycle focuses on a set of priority issues for the health, well-being and rights of children also for the whole population of Nepal. A steering group from the National Planning Commission, Central Bureau of Statistics and relevant line ministries agrees the focus of each cycle. The Steering Group nominates a technical group to develop and agree the cycle plan and instruments of data collection for each cycle as well as to play a key role in interpreting NMIS results and ensuring their use.
The four cycles of NMIS that have taken place so far are: Cycle 1 on Health and Nutrition1 in early 1995; cycle 2 on Primary Education8 in spring/summer 1995; cycle 3 on Diarrhoea, Water and Sanitation9 in the first half of 1996; and cycle 4 on early childhood feeding, nutrition and development10 in the autumn of 1996. Reports on these first four cycles are available1,8,9,10.
This fifth cycle of the NMIS focuses particularly on women's access to and experience of antenatal and delivery care. This is timely in view of the recent publication of the National Maternity Care Guidelines for Nepal11. 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.
This fifth report in the NMIS Series includes a brief section in the Introduction on relevant existing data in Nepal, and the government strategy for promoting safe motherhood. The Methods section includes a background to the methodology used in the NMIS, which will be relevant especially for those readers who have not seen the first four reports in the NMIS Series1,,8,9,10. The methods used in the fifth cycle are described, including the instruments used and the sources of data from households, institutions, key informants and focus groups. The Results section gives the results of a descriptive analysis of the levels of antenatal care, delivery care and other practices during pregnancy and delivery, and information about the outcome of reported pregnancies in terms of the size of the baby and whether or not the baby survived. It includes a univariate risk analysis of those variables having an effect on the risk of not receiving antenatal care and of an adverse outcome of the pregnancy (undersized baby or death of the baby). It also shows the results of the risk analysis to examine the effects of variables in combination on the risk of not having antenatal and delivery care or of an undersized baby or death of a baby. It includes estimates of the possible effects of different interventions aimed at improving antenatal and postnatal care. Results disaggregated geographically and by ethnic group are given in Annex 5.
Note that in this fifth cycle of the NMIS there was no attempt to estimate maternal mortality. Recent estimates of the maternal mortality in Nepal are available from other sources12,13. Nevertheless, it includes data on access to emergency obstetric care and other variables known to be associated with maternal mortality. If it can indicate ways in which these indicators can be improved, this would be expected to result in a reduction in maternal mortality.
This report and the reports of cycles 1, 2, 3 and 4 are only part of the process of communicating the results of the NMIS to those who need them for planning and development at national, local, community and household levels. The findings of cycles 1-4 have been discussed with decision-makers and planners in a number of different fora, including with Chairmen of District Development Committees (DDCs). For cycle 5 it will be particularly important to discuss the findings with health care planners and providers in both government and NGOs. Their actions can translate the potential benefits indicated by the information from NMIS cycle 5 into real benefits for women and the next generation of Nepali children.
CIETinternational facilitated a two-week workshop on the methodology used in the NMIS and the findings of the third cycle in Kathmandu in May 1996 for staff of the Central Bureau of Statistics (CBS). This was intended to build capacities for their increasing practical involvement in the NMIS process. The CBS has taken on the task of data collection and data entry for the NMIS as from cycle 5. A two-week workshop on analysis of the findings of NMIS cycle 5 was facilitated by CIETinternational in Kathmandu in September 1997. This was attended by staff in the CBS as well as several other Nepali statisticians and demographers.
Work on planning and implementing a communication strategy on the results of the NMIS is currently being undertaken, with the support of UNICEF. This includes establishing a network of all organisations, mainly NGOs, working on development issues in the different districts of Nepal. This network can be a key channel for communicating messages derived from the NMIS cycles, since many of the organisations have frequent contact with communities and are active in promoting literacy as well as providing services in health and other sectors.
Pregnancy and delivery care and outcome in Nepal
Maternal mortality
According to the 1996 Nepal Family Health Survey12, 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 Survey13
estimated the MMR as very similar: 515 deaths per 100,000 live births. However, according
to the State of the World's Children of 199814
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.
Table 1. Estimates of Maternal Mortality Rate in South Asian countries.
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*Source: The State of the World's Children, 1998
**Source: NFHS- 1996, Ministry of Health
Maternity care standards
Partly in response to the high maternal mortality rate, the Ministry of Health, HMG of Nepal issued the National Maternity Care Guidelines in 199611. The guidelines point out that the provision of appropriate care for women during pregnancy and childbirth is essential to ensure a healthy and successful outcome of pregnancy for the mother and her newborn infant. Most women in Nepal reside in rural areas, where only basic health care services are available at the Health Post (HP) and Sub-Health Post (SHP), with some community-based services provided by trained Traditional Birth Attendants (TBAs) or Female Community Health Volunteers (FCHVs). The capacities of the various health worker categories vary and may not be sufficient to allow them to respond to women's needs effectively. Furthermore, access to health facilities is limited by difficult terrain, lack of roads and lack of transport facilities. The National Maternity Care Guidelines11 define the basic care that should be available for women and newborns during pregnancy, delivery and the post-natal period, and set the national standard for maternity care in Nepal.
The Annual Report of the Department of Health Services 2053/54 (1996/97)15 includes indirect estimates of maternity care coverage. The report includes data from health facilities, with estimates of coverage based on expected numbers of pregnancies. On this basis, it estimates that 21% of expected pregnancies had at least one antenatal care visit in 1996/97, and that 6% of expected deliveries were attended by a trained TBA or other trained health worker.
NMIS cycle 5 examines the current maternity care situation in Nepal directly, allowing comparison with the standards of the National Maternity Care Guidelines.