Please cite this paper as: Malla DS, Giri K, Karki C, Chaudhary P. Achieving Millennium Development Goals 4 and 5 in Nepal. BJOG 2011;118 (Suppl. 2):60–68.
The under 5 child mortality rate in Nepal is on track to achieve the target of 54 per 1000 live births by 2015 compared with 158 per 1000 live births in 1991. The maternal mortality rate also looks set to drop to its target of 134 per 100, 000 live births by 2015 from 539 per 100, 000 live births in 1991. A 3-year interim plan (2008–11) was established to provide free basic health care for all citizens and the safe delivery incentive programme has proved to help progression towards achieving Millennium Development Goals 4 and 5. The development of a policy targeting women, children and vulnerable populations in hard to reach places is a key feature. The principle of a primary healthcare approach is applied in the development and implementation of strategy plans and programmes. The focus is on ensuring that there are functioning facilities for essential obstetric care at health facilities and provision of trained personnel at delivery.
Nepal is situated in the lap of the Himalayas with diverse topography and a population with multi-ethnic characteristics. The Safe Motherhood Program (SMP) was identified as a priority programme after the Safe Motherhood Conference in Nairobi in 1987, and the primary healthcare approach was institutionalised in 1991.1 The Safe Motherhood Plan of Action (1994–97)2 and the National Safe Motherhood Long Term Plan, 2002–17 (now the National Safe Motherhood and Newborn Health Long Term Plan, 2006–17)3 served as the basis for implementation of safe motherhood interventions. In 2004, the Government of Nepal (GoN) introduced the ‘Health Sector Strategy: An Agenda for Reform’.4
The GoN adopted a sector-wide approach to improve aid effectiveness by coordinating the efforts of the government and external development partners to put the country on track to achieve the 2015 Millennium Development Goals (MDGs) for health. The Interim Constitution established the right of all Nepali citizens to free basic health services, the right to a clean environment, access to education and a means of livelihood, in a social environment free from discrimination and institutionalised inequality.5
The Ministry of Health and Population (MoHP) and the Ministry of Women, Children and Social Welfare worked together using the Nepal Health Sector Strategy as a guiding principle as it has an escalated focus on women’s empowerment, education, gender equity and legal rights. Women received the right to vote and have been able to confer their nationality on their children since 2006. The Maternity Incentive Scheme (MIS) has contributed to the increased utilisation of the health services. These are all activities which it is hoped will contribute towards achieving the MDGs.
Nepal is a low resource country where maternal death rate and reproductive morbidity is very high. The factors which contribute to the delay in reaching care include difficult terrain and absence of appropriate transport. Lack of adequate healthcare facilities and trained health personnel and provision in existing facilities is still a constraint. Although improvement can be seen in the seeking of care during pregnancy and childbirth, three delays still need to be addressed.
Maternal and neonatal health statistics
The total population of Nepal is 28 million of whom 49.84% are female.6 The total fertility rate was four in 2001 and 2.9 in 2009, while the target for 2015 is 2.5. The contraceptive prevalence rate (CPR) was 47% in 2001 and 51% in 2010 with a target of 67% for 2015.7 According to the Nepal Demographic Health Survey 2006, ‘19% of women aged 15–19 have already had a birth or are pregnant with their first child’.8 The adolescent birth rate was 84.0 per 1000 for 2001, 106.3 per 1000 for 2004 and 106 per 1000 for 2008.8,9
According to the World Health Organisation Trends in Mortality report, the maternal mortality ratio (MMR) in Nepal has decreased from 870 per 100 000 live births in 1990 to 380 per 100 000 live births in 2008 – that is a 56% decrease in MMR during this time. It seems that MDG 5 is certainly achievable in Nepal.10
The perinatal mortality rate decreased from 47 per 1000 to 45 per 1000 births between 2001 and 2006.8 The neonatal mortality rate and infant mortality rate reduced from 39 to 33 and 64 to 48 deaths per 1000 live births respectively in the same period.8,11
Specific targets for MDGs 4 and 5 for the country
The findings of the demographic and health surveys in 1996, 2001 and 2006 indicate that Nepal has come a long way towards meeting the target of the MDG in terms of child mortality, maternal mortality and CPR. The targets for Nepal are shown in Table 1.
Table 1. Table with specific numbered MDG 4 and 5 targets for the country
Millennium Development Goal 5: 5A: Reduce maternal mortality by three quarters between 1990 and 2015
*The figures mentioned in our chart is given as it is inside the bracket but the available data are for 1991(1990), 1996(1995), 2001(2000), 2006(2005), 2009(2010) and (target) 2015.
**Nepal Family Health Survey (1996).
***Ministry of Health, New ERA and ORC Macro (2001). Nepal Demographic and Health Survey 2001.
****Ministry of Health, New ERA and ORC Macro (2001). Nepal Demographic and Health Survey 2006.
*****Department of Economic and Social Affairs, United Nations Statistics Division, United Nations. Retrieved July 30, 2010, from Millennium Development Goals Indicators official site for United Nations’ MDG Indicators.
******Nepal Family Health Survey (1991).
Maternal Mortality Ratio (MMR)
Proportion of births attended by skilled health personnel (SBA)
5B: Achieve universal access to reproductive health by 2015
Contraceptive prevalence rate
Adolescent birth rate
Antenatal care coverage (at least 1 visit) and (at least 4 visits)
Unmet need or family planning
Millennium Development Goal 4: Reduce child mortality by two-third between 1990 and 2015
Under five mortality rate
Infant mortality rate
Proportion of 1 year old children immunised against measles
Continuum of care
There has been considerable progress in the care of women during the antenatal period: 71.8% of women came for first visit during 2006–7 compared with 26.9% during the year 1998–99.8 The first visit usually occurs during the first 4 months of pregnancy. The women receive antenatal care in hospitals, primary healthcare centres and outreach clinics. Between 67% and 71% of women receive antenatal care. However, skilled antenatal care (from skilled birth attendants (SBAs)) remains patchy and uneven: levels of antenatal care are highest in the central hill and mid-western terai subregion (64%) and lowest in the far western hilly subregion (25%). Socio-economic disparities are also present in antenatal care uptake: urban residents (85%) have a 2.26 times greater coverage of antenatal care provided by an SBA than the rural residents (38%).
The percentage of women who made four or more antenatal care visits increased from 9 to 29% between 1996 and 2006. During antenatal visits, women are given tetanus toxoid injections and iron and folic acid supplements. Identification of pregnant cases, especially in remote villages, by female community health volunteers (FCHVs) has made a difference – women who attended the women’s group were more likely to utilise antenatal care services.8
The majority of births continue to take place at home and without the assistance of an SBA. In Nepal, there is a lot of variation in the geographical distribution and number of institutional deliveries as well as the presence of SBAs. It ranges from 2 to 27%. For women delivered in health facilities, strong urban (48%) and rural (14%) differences were also found.8 Urban residents (51%) were 3.5 times more likely to be attended by an SBA than rural residents (14%). Births in the hill zone, in the central region and especially in the central hill subregion are most likely to be attended by an SBA.
Overall the institutional delivery rate has increased from 9% in 2001 to 19% in 2006 (Figure 1).
The number of births attended by an SBA, either at home or in an institution, has also increased and was reported to be 7% in 1991, 29.7% in 2006 and 31.6% in 2009. This could reflect the importance of the incentives schemes which were started in 2005.12 The target for 2015 for Nepal is 60% of births to be attended by a skilled healthcare provider.
The National SBA Policy was developed in July 2006 by the MoHP. Since then there has been an expansion of training sites for core skills and also in the number of trainers in order to meet the target of providing 4573 SBAs by 2015 needed to achieve 60% coverage. This requires Nepal to train 1200 SBAs per year.13
In Nepal it is recommended that postnatal care is provided by an SBA within 7 days of delivery. This is for identification and treatment of complications, referral when needed, promotion of exclusive breastfeeding and immunisation of the newborn. The utilisation of postnatal care is low but improving in Nepal: around 33% of women attended postnatal clinic in 2007–8 compared with 17% in 2001. The majority of women received care within 48 hours of delivery. The care varied between women who delivered in health facilities and those who delivered elsewhere, 56% of the former having a postnatal check-up within 4 hours compared with only 16% of the women delivered in the second group.14 Implementation of postnatal care has reduced neonatal death and maternal morbidity from sepsis. The common postnatal problems recorded include malnutrition, anaemia and night blindness.15 Uterine prolapse is common in Nepal with many women suffering in silence, unaware that it can be surgically treated. Recent studies have shown that the prevalence of prolapsed uterus ranges from 10 to 40%.16
The family planning programme has been a priority programme of the GoN but the expected result has been modest. Counselling and provision of family planning commodities is available at all health facilities.17 All levels of care providers are involved in increasing the CPR. The CPR (any modern method of contraceptive used by women aged 15–49 years) in urban areas is 54.2% and 42.5% in rural areas. The total fertility rate is 2.1 in urban and 3.3 in rural areas.17 The most important factor contributing to fertility reduction in Nepal is considered to be contraceptive use.
The Maternal and Neonatal Health Care Strategy has helped in reducing neonatal mortality. Community interventions have shown impressive results when the women’s group approach is used. This was shown by a study in Makawanpur where a 30% reduction in newborn mortality over 2 years was noted. This reduction will have a positive effect on the under-5 infant mortality rate.15 Breastfeeding immediately after delivery has been identified as one of the best practices.
Care for infants aged under 5 years
Once the child has survived the neonatal period, the child is likely to encounter a range of new threats to its survival. Community Based Integrated Management of Childhood Illness (CB-IMCI) is an integrated package of child survival programmes and addresses major killer diseases such as pneumonia, diarrhoea, malaria, measles and malnutrition in children under 5. The National Immunisation Programme is a high priority programme of the GoN. The National Nutrition Programme has a mission to improve the overall nutritional status of children and women of childbearing age and pregnant women through control of general malnutrition and micronutrient deficiency disorders.13
Causes of maternal and newborn mortality and morbidity
The major causes of maternal death in Nepal are haemorrhage (24%) and eclampsia (21%).14 Thirty-four percent of all maternal deaths occur during the antepartum period, 38% occur during the intrapartum period (including death within 48 hours of delivery) and 28% of all deaths occur during the postpartum period (including cases 48 hours after delivery). The Nepal Maternal Mortality and Morbidity Study (MMMS) 2008–9 reports that death occurs in health facilities (42%), at home (41%), during transit to facility (7%), between facilities (5%), at the medical shop (2%) and at the home of the service provider (1%). Two percent occurred in other places such as in the jungle or in a cowshed.14
The proportion of pregnancy-related deaths due to direct and indirect causes has increased from 84% in the 1998 MMMS study to 93% in the 2008–9 study. Deaths due to accident or incidental causes (suicide) increased from 33% in 1998 to 46% in 2008–9. There has been a substantial change in the proportion of deaths due to direct causes, which have reduced from 84% in 1998 to 69% in 2008–9, with an associated increase in the proportion due to indirect causes from 16 to 31%.
Haemorrhage was the leading cause of death in both these studies. However, the percentage contribution of haemorrhage to maternal causes has dramatically reduced from 43% in 1998 to 24% in 2008–9. This decline reflects a reduction in postpartum haemorrhage (PPH) (both with and without retained placenta) from 39 to 18%, rather than a reduction in antepartum haemorrhage.14 For women with complications referral to a facility is increasing. The caesarean section rate has increased by three times in a decade. And there has also been an increase in SBAs at delivery.18
Among neonates, infection accounts for 30% of deaths, birth asphyxia/birth injury 33%, congenital abnormality 7.5% and low birthweight 6%, with other causes contributing 13.4%.11 Substantial progress has been achieved in the control of childhood diseases since the CB-IMCI programme was expanded to community level. The contribution of immunisation has also been a significant factor in reducing child deaths in Nepal.19
National strategies to address MDGs 4 and 5
Overview of health policies
The National Health Policy was adopted in 1991 with the objective of enhancing the health status of the population of Nepal through extending the access and availability of the primary healthcare system. The policy addressed preventive, promotive and curative services through improvements in organisation and management. The policy also focuses on development of human resources for health, resource mobilisation, community participation and health facility expansion.7
The National Health Strategy is broadly organised in two components: (i) strengthening service delivery, and (ii) development of institutional capacity and management. As a medium-term strategy and implementation plan for reaching the MDGs, the country’s tenth plan incorporated MDGs into its strategic framework. Based on the policy of the GoN, strategies are formulated for the areas of Human Resource for Health (HRH) development, improved financial management, expanding healthcare facilities, community empowerment and institutional capacity building.
The HRH strategy, including the SBA strategy, has helped in the development of much needed human resources and provision of trained healthcare providers. To deal with the different financial barriers effective programmes such as the Safe Delivery Incentive Program (SDIP), the Aama Surakchhya Karayakram maternal health programme and improved donor coordination have been developed. The strategy to expand health facilities, even in the difficult to reach areas, has been developed into an effective programme. This also includes outreach clinics for antenatal care, vaccination and organisation of health camps.
The empowerment and involvement of the community for improved care of the mother and newborn baby is another strategy that involves FCHVs, mother’s groups and the Men as Partners (MAP) Programme. The drive for institutional capacity building and development has helped ensure improved blood transfusion services, drug supplies and health research for evidence-based policy and practice.14
Programmes and policies to implement strategies
The Safe Motherhood and Neonatal Health (SMNH) long-term plan (2006–17)3 identifies the need for phased strengthening and expansion of quality SMNH services at all levels, especially the number and quality of Basic and Comprehensive Essential (Emergency) Obstetric Care (BEOC and CEOC) sites and birthing centres. Since the majority of women still give birth at home, the aim is to ensure that normal delivery care and referral services are available at community level through home visits and outreach clinics. The Health Posts, Sub-Health Posts and 24 hour birthing centres are able to manage normal deliveries. The goal of the SMNH plan is to improve maternal and neonatal health and survival, especially for the poor and excluded.
There are specific outputs identified in the plan including equity and access, public–private partnership, decentralisation, human resource development, SBA strategy, information management, physical assets and procurement and finance.
Both the MIS and SDIP are in demand and are successful demand-side initiatives to promote institutional birth and ensure increased SBA coverage. However, ensuring quality and regular flow of funds are essential prerequisites for sustainability of this innovative approach. The Equity and Access Program in selected districts has helped to empower women not only to utilise health services but also to raise their voices to request that their basic health rights are met (Figure 2).
The Support to the Safe Motherhood Program (SSMP)20 supports the delivery of and access to quality maternal and newborn health services, including human resources, infrastructure investments, demand-side financing, equipment supplies and comprehensive abortion care (CAC).
There are efforts specifically directed to achieving improvements in maternal and neonatal health which focus on improved care at the health facility level. The upgrading of health and sub-health posts was initiated in 2008–9 and the numbers of health assistants and auxiliary nurse midwives will each be increased to over 3100.21
The introduction of FCHVs who are based in the villages near the mothers and children has proved to be a practical and well accepted programme. The major role of the 50 000 FCHVs is to promote health and healthy behaviour for safe motherhood. The village residents are given knowledge about birth preparedness which includes information about care facilities and care providers, the clean delivery kit, financial arrangements and about the MAP Program. Through the Community Based Maternal Neonatal Care programme the FCHV provides antenatal health education, promotes seeking care from an SBA and educates women about the Birth Preparedness and Complication Readiness package. The FCHV is selected by the mother’s group (an active women’s group for women) who can identify the dedicated women in the community. The potential of the women’s group to bring about improved health-seeking behaviour and improvement in health outcomes was examined through a randomised control trial; a staggering 30% reduction in newborn mortality and a significant reduction in maternal mortality over the period was demonstrated.15
Essential obstetric care (EOC)
The UN process indicators are being used to monitor the SMP in 19 selected districts and this has been found successful in deciding how to expand the service sites (Tables 2 and 3).
Table 2. Essential obstetric care
Existing status in 2006
Required sites by 2017
Coverage of CEOC
44 sites (33 districts)
Coverage of BEOC sites
81 sites (53 districts)
Table 3. Availability of CEOC/BEOC and birthing sites by 2009
26 districts and 34 sites
33 districts and 51 sites
35 districts and 79 sites
13 sites (8 hospital, 5 PHCC)
68 sites (31 hospitals, 37 PHCC)
90 sites (42 hospitals, 48 PHCC)
Birthing service in PHCC
Birthing service in HP
138 HP in 2007/2008
The CB-IMCI programme recommendations are to mobilise the community health workers and FCHVs to improve availability of the management of childhood sickness at the household level. The success of the rapid scaling-up of the programme lies in its implementation modality which is an example of close collaboration and public–private partnership between stakeholders.7
Immunisation is considered to be one of the most cost-effective health interventions. It has significantly contributed to reducing the burden of vaccine-preventable diseases and child mortality.
The National Nutrition Program under the Department of Health Services has outlined its vision as ‘all Nepali people should have nutrition, food safety and food security for adequate physical, mental and social growth and development and survival’.
The National Maternal Mortality Review Committee was established in 1998 to audit maternal deaths. It is now called the Maternal and Perinatal Death Review Committee (MPDRC). It reports on causes of death and preventable factors in cases of institutional maternal and perinatal death. Prior to cases being reviewed by the MPDRC, the records are reviewed first by the specialist in charge in the maternity and neonatal unit where the death occurred, after which they are reexamined by the committee under the chief of the hospital to assign the cause of death.
Prevention of mother-to-child transmission (PMTCT) of HIV is an important part of the National HIV and AIDS Strategy. The PMTCT service was expanded to offer paediatric antiretroviral therapy and sites to provide CD4 testing. Beside this, a community-based PMTCT service is available up to primary healthcare centre, health post and sub-health post levels. HIV/AIDS is an upcoming health challenge in Nepal and has been identified as a cause of indirect maternal deaths in the last MMMS.
Achievements to date
To meet the challenge of human resources needed to help achieve the MDG targets, the SMP has increased training of SBAs (doctors, nurses and auxiliary nurse midwives). The WHO has supported the Nepal Ministry of Health and other development partners to give this issue high priority.22 One study indicates that task shifting can prove to be an effective short-term solution to the healthcare worker crisis in Nepal and advises that Nepal should begin to incorporate this in its national healthcare strategy.23 Maternal and neonatal health care has been included in different medical curricula of Nepal. The GoN strategy for development of human resources for health has resulted in helping to provide the different categories of healthcare personnel in the increasing number of health facilities that are needed for maternal and neonatal care.
[ Girls and women centered strategy and program. ]
There have been other successful training programmes such as anaesthetic assistance training for staff nurses and health assistants, post-abortion care and CAC training for doctors and nurses, advanced SBA training for medical officers and a new diploma programme in obstetrics and gynaecology. The availability of post-abortion care and CAC at primary health care centre level has played a role in reducing abortion-related maternal deaths in Nepal. The nurses being trained to provide these services have ensured continuity of care in the peripheral health facilities. Enabling SBAs to provide active management of the third stage of labour by using oxytocics has helped the prevention of PPH.
The initiation of the nationwide Maternity Incentives Programme in 2005 has proven to be useful. Incorporation of more institutions through the SDIP in 2006 has increased the number of women delivering in health facilities.7
On 14 January 2009, the Government launched its national Aama Surakchhya Karayakram maternal health programme, which has two components: free child birth and travel cost to women, aiming to reduce both the first and second delays to avert maternal deaths. Early in 2009, the MoHP began to provide free institutional delivery care (normal, complicated and caesarean section) for every woman at all facilities capable of providing these services. This has led to a significant increase in the reported number of facilities providing delivery services.
Investigation of the MMMS has helped to identify evidence-based interventions for prevention of maternal mortality and morbidity. Sending maternal and perinatal death audit forms from district hospitals to the Department of Health Services is aimed at improving the understanding of the causes and contributing factors of institutional deaths of both mothers and newborn infants. Safe abortion services in 75 districts (239 government service delivery sites) have helped in preventing abortion-related maternal deaths in the country. Six training sites and ten service delivery sites for second trimester CAC services are additional facilities available. The public–private partnership programme of the GoN has resulted in escalated achievements in family planning services of the country. The programme of strengthening and increasing accessibility of selected Primary Health Care Centres (PHCC), including the provision of emergency contraceptives in these facilities, has contributed to the reduction in fertility rate.
The programme of community interventions has started showing its effects on the health statistics of the country. The role of the FCHV has been crucial. These women care providers, who are non-health professionals, are engaged in providing safe motherhood health education and referral, a birth preparedness package, iron supplementation and drugs (misoprostol) for prevention of PPH. For the improvement of child health, there is the development of essential newborn care, including Kangaroo Mother Care (for low birthweight babies in selected districts), and it has shown that cost-effective interventions can reduce the infant mortality rate. The FCHV also helps in family planning counselling and referral, and distributes the pill and condoms.24
Despite the contextual difficulties and constraints, Nepal is on track to achieve the MDG 4 and 5 targets if the prevailing trend persists and efforts are continued or improved.19 The GoN and people (men and women) are committed to retaining the gains made to date and supporting the needed activity to maintain a healthy family (mother and children) and society in future by strengthening the health system based on the primary healthcare approach. This is considered to be the key to achievement of the health-related MDGs.25
Challenges and opportunities
The delays in seeking, reaching and receiving care are important contributors to poor maternal health in Nepal. The vast majority of births still take place at home without skilled care.
The need for policy and strategy to deal with the multiple constraints such as insufficient health infrastructure, low utilisation of health services and barriers to access of health facilities (including financial) is important. Training of SBAs has been a continual process for the MoHP. The lack of an enabling environment, limited community ownership, lack of partners’ commitment for sustained support, conflict between demand and supply, are all factors that must be taken into consideration during programme development and implementation. The recent developments in advocacy and application of the primary healthcare principle in urban settings are a key step forward as urbanisation of the cities has increased tremendously in the last decade. Free healthcare services for all citizens and programmes such as SDIP and MIS have been instrumental to improving women’s and child health. The compulsory vital registration of birth and death is to be incorporated into service development.
Despite a steady increase in the CPR, successive national surveys in Nepal show that the prevalence of unintended pregnancy among women of reproductive age (15–49 years) increased from 25% in 1991 to 35% in 2001. A comprehensive approach is needed across the three services family planning, safe abortion and post-abortion care. This means ensuring the availability of CAC, namely the termination of unwanted pregnancies through safe technique with effective pain management, and post-procedure family planning information and services. In order to provide a safe abortion service, it is essential that doctors and nurses are trained. Training nurse providers in a safe abortion service is seen as an effective way to avoid service interruption.21
Will the MDG 4 and 5 targets be reached?
The targets for MDG 4 and 5 are at various stages of attainment. It will be a challenge to meet the target for SBA coverage of 60%. The unmet need for family planning is still high. The targets for maternal mortality and under-5 infant mortality are likely to be met for Nepal. The vaccination coverage is over 90%. The adolescent birth rate is high and will need concerted efforts to reduce it (Table 4). These figures indicate that the country is on track and the target for MDG 4 and 5 may be achievable.
Table 4. Will the MDG 4 and 5 targets be reached?
Target 5A: Reduce maternal mortality by three-quarters between 1990 and 2015
Maternal mortality ratio
Proportion of births attended by skilled health personnel
Target 5B: Achieve universal access to reproductive health by 2015
Contraceptive prevalence rate
Adolescent birth rate
Antenatal care coverage (at least one visit and at least four visits)
Unmet need or family planning
Target 4: Reduce child mortality
Under-5 mortality rate
Infant mortality rate
Proportion of 1-year-old children immunised against measles
Disclosure of interests
The authors Dr. D.S. Malla, Dr. Kanti Giri, Dr. Chanda Karki and Dr. Pushpa Chaudhari have not received any financial or other help from any commercial body within the past two years in relation to this article.
We wish to acknowledge Dr Ganga Shakya, Maternal & Neonatal Health Advisor, Nepal Health Sector Support Program, Ministry of Health and Population, for valuable advice and necessary help during the preparation of the document. We would also like to thank Mr Sujin Joshi for assisting us in preparing the presentation for submission and technical support. Ms Sudhira Acharya of the Family Health Division deserves special thanks for supporting us with departmental information.