By Kusum Thapa, FRCOG,MPH
Mana Maya* went into labor just before dawn in a small Nepali mountain village in the Himalayas. Alone at home with her mother-in-law and three small children, Mana Maya gave birth to a baby girl before complications set in. Her husband, a migrant worker, was not there when she began to bleed heavily. It was up to her elderly mother-in-law to walk the narrow track to the village to find two men to help carry her on a stretcher to the nearest health facility some 10 kilometers away.
Four hours later they arrived at the clinic where the only nurse on duty was unable to help her. Instead, she was referred to yet another facility. On the way, Mana Maya became one of the an estimated 1,200 Nepali women -- almost three a day -- who perish each year during childbirth.
Across the world, women and children are still dying in alarming numbers from preventable causes. Almost 300,000 women died globally in 2013 from causes related to pregnancy and childbirth. Every day, approximately 800 pregnant women die from childbirth.
Nepal, like many other developing countries, has worked hard to change this scenario, and managed to reduce the number of women dying in childbirth from 539 per hundred thousand live births in 1996 to just 170 by 2012. This progress came despite Nepal's decades-long political conflict which had a devastating impact on the country's development and diverted much needed resources.
Today Nepal is proud to be one of the few countries to achieve Millennium Development Goal (MDG) 5 -- one of a series of 15-year global development targets that the United Nations laid out in 2,000 which come due this month.
But, is being "on track" enough?
While Nepal's progress has been hailed, women are still dying. Failure to eliminate maternal mortality has a cost borne not just by the mothers at risk but also by the surviving family; what should be a joyous celebration results instead in a tragedy for the entire family.
There are many reasons women die during childbirth but for the vast majority of cases, delays in reaching an appropriate obstetric facility are the deciding factor. Moreover, those who do make it to a facility often find them lacking in quality care.
Nepal's mountainous terrain is also an important risk factor for maternal death. Women often have to walk miles before they reach a health facility that may or may not be equipped with to provide quality care. Now in the after math of the recent earthquake which has hit Nepal badly what does this mean. According to a United Nations Children's Fund (UNICEF) report, "at least 70 percent of birthing centers across the 14 most affected districts of Nepal have been damaged or destroyed, rising to 90 percent in some areas." With surviving facilities overwhelmed, hundreds of pregnant women have been left without access to the health care they need to ensure the safe delivery of their babies. Some Health Workers have died and many have been displaced leaving facilities without adequate human resources to provide the necessary services.
In other countries where I have worked, there are other risks. In Myanmar, for instance, the decline in maternal mortality is very slow. In 2014, Myanmar had one of the worst maternal mortality rates in the region -- 200 deaths per 100,000 live births, according to unric.org. The country will not reach the MDG goal of 130 deaths per 100,000 live births by 2015, according to UNFPA. Like Nepal most of the deaths are related to bleeding after birth and hypertension. The UNFPA notes that 87 percent of maternal deaths occur in rural areas, where poor infrastructure and the lack of reproductive health access are contributing factors.
As world leaders meet in New York to review the MDGs and agree on new Sustainable Development Goals (SDGs), mother and child health must remain on top of our agenda.
There must be a concerted effort to ensure universal access to both skilled antenatal and delivery care particularly for the vulnerable such as Mana Maya. We must concentrate on four key factors: Availability, Accessibility, Acceptability and Quality of Maternal and Newborn care.
This means facilities must be strategically located and adequately staffed. Urgent investment in high-quality midwifery care could prevent about two-thirds of all maternal and newborn deaths, says the 2014 State of World Midwifery report. This translates into millions of lives saved every year. It is clear that recruitment and deployment and of trained midwives in the community is imperative.
We also need to connect more women to treatment. Mobile communications devices, such as mobile phones, can help surmount the geographical barriers separating women in need from quality care. Equally urgent is the need to improve the country's referral system. Nepal has 75 districts -- each of which should have a designated hospital capable of handling emergency maternal complications. Emergency funds at the referral facilities would facilitate easy referral. Making stretchers available for the community has been effective though we need to also consider who would be carrying these; so many Nepali men are forced to seek work abroad, leaving women alone in the home.
Our success relies on involving everyone. It also means that we listen to the views of the women we endeavor to help. This points to a needs-based, bottom-up planning -- not a blanket approach -- to guide our efforts, ensuring effective and efficient use of resources. Focused efforts in rehab and restoration is equally important and this needs to be speeded up.
It's true, of course, that more resources will be required to implement these interventions. But the amount needed is negligible in comparison to the benefits accrued -- saving these mothers would affect the family, the society and the nation as a whole.
Strategies such as these, if properly implemented, would have helped save Mana Maya and prevented this family disaster. Nepal has done well in reducing the maternal mortality rate and meeting the MDG 5 goal. But, women are still dying. Its too early to take our eye off the ball.
Dr Kusum Thapa is ANE regional technical advisor for Jhpeigo and president elect of the Nepal Society Of Obsteterians and Gynaecologists. She is a 2015 Aspen New Voices Fellow. Follow her on Twitter @DrKusumThapa
*Not her real name