I have attached the file which I had submitted earlier. I scored very poor marks and it was plagiarized so I need a research essay in the same topic by tomorrow. This is my supplementary assessment so I need to pass in any cost.
High Maternal Mortality Rate and it’s affecting factors in Nepal
In developing countries, especially in low-resource settings rural and poor communities, maternal health is still a public health problem. The main objective of this essay is to dig out the situation of maternal health in Nepal based on different resources and articles written regarding maternal health. There are several direct or indirect preventable causes in Nepal causing maternal death which will be further discussed in the essay. World Health Organisation (WHO) defines maternal health as, “the health status of women which occurs during pregnancy, childbirth, and the postpartum period, which incorporates the health care dimension of family planning, preconception, and prenatal and postnatal care to reduce maternal morbidity and mortality”. Similarly, According to WHO, “maternal death refers to death of a woman while she is pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any causes related to or aggravated by the pregnancy or its management but not from accidental or incidental causes” which should not be occurred due to any chronic disease or any other health condition.
Worldwide about 140 million women give birth every year. Every day, approximately 830 women die from preventable causes related to pregnancy and childbirth. Most of deaths are caused by haemorrhages, sepsis, hypertensive disorders, prolonged or obstructed labor, and unsafe abortions (Rosenfield, & Maine, 1985). Despite its recognition as an important and complex health issue, it was not until 1980s that maternal mortality was added onto the international health agenda as a major public health issue (Suwal, 2008). The situation concerning maternal mortality in Nepal remained unexplored and vague until the early 1990s. Between 2016 and 2030, as part of the Sustainable Development Goals, the target is to reduce the global maternal mortality ratio to less than 70 per 1,00,000 live births. 99% of all maternal deaths occur in developing countries rather than in developed countries. Maternal and child health care services is essential component to promote family health in Nepal has made remarkable strides in improving the health of its people. Nepal has been noted for its remarkable achievement in bringing down the number of maternal deaths by more than 75 percent since 1990, as well as for significantly reducing under-5 child mortality by more than 66 percent over the past 20 years. Currently the national under-5 mortality is 39 per 1000 live births, while maternal deaths are estimated at over 32 deaths per 1000 live births (MoH , 2017). Only 57 percent deliveries occur in health institution and nationally only 58 of the deliverables are attended by trained health providers (MoH, 2017).
Sustainable Development has been a global agenda for the last 25 years. The Millennium Development Goals (MDGs) declaration by the United Nations has set foundation for Sustainable Development Goals (SDGs) to be achieved by 2030. All the targets under child health – reducing infant mortality rate (IMR), reducing under five mortality rate (U5MR), and increasing immunization against measles have been met. The IMR dropped from 64 per 1,000 live births in the year 2000 to 33 in 2015; and U5MR declined from 91 per 1000 live births in 2000 to 38 in 2015. Nepal was close to meeting the targets of reducing the maternal mortality ratio (MMR). Nepal has made several efforts to address such inequities in health care. One example is the establishment of birthing centres (BCs), which act as initial institutional contact points for birth at a local health facility. It provides access, quality services and promotes institutional delivery for the marginalized people in rural area.
According to the Nepal Maternal Morbidity and Mortality Study (2008–2009), the leading causes of maternal death in Nepal were haemorrhage, then eclampsia, abortion-related complications, gastroenteritis, and anaemia. As per the study, 69% of maternal deaths were caused due to direct causes and the remaining 31% were due to indirect causes. The major factors influencing maternal mortality rate in Nepal are home delivery, unsafe abortion, traditional birth attendants, family planning and fertility, health services and affordability, communication and transportation and education and knowledge.
Home delivery
It is one of the most influencing factors of maternal mortality in Nepal where almost 90% of births occurs at home. To reduce the risk of maternal complications, a skilled health worker is required in the community to conduct safe delivery in the home setting. The percentage of home deliveries is still high in Nepal with 63.1% of deliveries occurring at home and only 35.3% of deliveries occurring in a health facility. As suggested by WHO, first-time delivery is very necessary to be in a health facility for the maternal health. If by any chance it takes place at home, then a skilled health professional should necessarily be there, and the mother should visit a health facility or a skilled health professional within 2 hours of delivery to reduce the complications of delivery.
Unsafe abortion
It is the direct cause of maternal death in Nepal. In rural parts of Nepal, unsafe, unhygienic, and sometime dangerous practices have been undertaken which cause unexpected maternal deaths. This is due to the lack of proper knowledge regarding safe delivery, lack of health awareness, unavailability of health services in rural communities. Abortion services have been offered in public hospitals or health centres with trained health professionals since 2002 after abortion has been legalised in Nepal.
Traditional birth attendants
Major factor affecting maternal health in Nepal is Traditional birth attendants (TBAs). In the context of a quality health care service, most of them are not well trained to conduct delivery safely. Their practice put the health of women in danger as they use traditional methods to conduct the delivery at home. During antenatal care, delivery, and the postnatal period, TBA’s have been playing major role in the community. As the cost of the service provided by TBA’s is less than that of other private or government health workers, women can be easily benefited from them in the community. TBA can be found everywhere in Nepal. Because of insufficient trained professionals, TBAs are the only source of maternal care during pregnancy and delivery in the rural parts of the country. The services differ with the cast and culture among the TBAs. For many years they have been providing traditional and culturally suitable services to women in the community. Although, skilled birth attendants have been using a safe delivery method instead of the traditional technique, there is still a long way to go to reduce maternal mortality. As per the latest survey, only 36% of pregnant women have been receiving the delivery service from skilled birth attendants during pregnancy in Nepal.
Family planning and fertility
Family planning is another vital factor affecting maternal health in rural society in most of the developing countries. The key obstacles to the use of family planning are lack of sufficient family planning devices, little knowledge about family planning and difficulty in getting the devices. It is the safest way to prevent an unwanted pregnancy, an unsafe abortion and its complications. The total fertility rate in rural Nepal is 2.8 whereas it is 1.6 in urban Nepal which shows that the focus should be given to rural Nepal to reduce the fertility rate.
Health services and affordability
The key factors to reduce maternal mortality are the lack of health services and the quality of the health care services. Health workers are very few, but the flow of patients are very high which results in less or no privacy for patients to explain the problems to the health worker in outpatient department (OPD) in the hospital. Because of being properly trained, skilled and qualified health worker cannot maintain confidentiality and the privacy of women. People cannot afford the cost of essential health services, as Nepal is a poor and underdeveloped country. The major obstacles to the use of maternal health services are the total expenditures for treatment such as direct checking fee and the cost of transportation, medicines, and other supplies. Health facilities with trained health worker along with quality health care services are not available sufficiently in all parts of the country.
Communication and transportation
To receive the maternal health service, women who live in rural communities are compelled to walk long distance to reach the health center, health post, or a private clinic. In hilly areas of Nepal, women have no other option than using human porter service to go to the health post or hospital which means the distance and availability of transportation are basic factors to access health care services. In rural parts of Nepal, there are few roads and insufficient bridges over rivers which makes difficult to travel from one side of the river to the other. It is even more problematic for pregnant women of low economic status to take advantage of a good health care services which compels them to receive health services from nonskilled health workers or traditional service providers, who are easily accessible in the community. This is indeed a real threat to the lives of the mothers and their newborns.
Education and knowledge
A lack of education and a lack of essential knowledge about maternal health are key factors affecting maternal mortality. Knowledge and education determine the health-care-seeking behaviour of women which are the key factors affecting maternal mortality. Educated women are more aware to use proper health care facilities than those who are not educated. Education empowers women to use the maternal health care service, which can be helpful for their personal development as well as to improve confidence and decision-making power.
Case Study of Karnali Zone
The Nepalese civil war that lasted from 1996-2006 led to displacement of more than 70,000 and resulted in more than 13,000 deaths (Bohara et al. 2006; World Bank 2007). Whilst the conflict ended after the signing of the Comprehensive Peace Agreement in November 2006, the civil war had severely undermined the already existing poor level of health services and had caused a negative impact on socio-economics and health indicators, particularly on mid-western and western hill regions where the intensity of the war was high compared to the less affected areas of eastern hill sub region (Partap, U and Hill. 2012). More than thousand health posts were destroyed during the war (Devkota and Teijlingen ER. 2009). Government and non-government services that provided health initiatives were negatively affected (Keiveilitz and Polzer. 2002).
Although the child mortality rates reduced over the past decade, mid-west and western Nepal still ranks low compared to rest of the country. Malnutrition among the surviving children remains excessively high and is a major threat to the health of infants, adolescent girls and pregnant and lactating mothers. The common traditional complementary food – fried maize – is low in nutritional values with fruits and vegetables being used only when the children become sick. Traditional belief of young children being possessed by spirits and home remedies to address serious health concerns have attributed to further the illness and malnutrition among young children. Proper care during pregnancy and delivery is important for the health of both the mother and the baby. Access to proper medical attention and hygienic condition during delivery can reduce the complications and infections that may lead to death or serious illness for the mother and/or baby (WHO 2006). Survey data show that in Nepal, a skilled provider delivered 58% of the births in the 5 years preceding the survey and 57% were delivered in a health facility.
Childhood malnutrition is also one of the major leading causes of morbidity and mortality in Nepal. It is a complicating factor for other illnesses. The situation of child Malnutrition in Mugu is very high due to cultural, social, economic, educational and political structure. Malnutrition is very high in this district (1% Sever Acute Malnutrition and 17 % Moderate Acute Malnutrition) compared to the national figure (13% Acute Malnutrition). This could be due to the hard life style of population, insufficiency of food, lack of knowledge and appropriate child feeding and caring and negligence of the mothers for feeding practices to their children which is due to lack of education on available family planning services required for spacing, limiting and determining the numbers of children in the family.
The national maternal mortality ratio (281 deaths per 100,000 births) and neonatal mortality rate (33 deaths per 1000 live births) is decreasing but is still high. In addition, in Mugu the maternal mortality rate is feared to be more than double of that, 700 per 100,000 births. Maternal death in Mugu per 100000 live births is 4 (OHS 2011) which could be saved with quality safe motherhood program, good female education and community awareness with sensitization on what are the services available, what are free of cost, the minimum 4 Antenatal visits offered for the pregnant women, the incentives provided to them for the institutional delivery and timely referral to the centres as delay in deciding, delay in seeking and delay in receiving the safe motherhood program is the major cause of the maternal mortality in Nepal where the safe motherhood services are available. Similarly, the neonatal death alone in Mugu is also very high i.e. 14/ 1000 live births out of 33/1000 live births nationally despite the government's high priority to reduce under five mortality rates from present 91/1000 live births to 62.5 per 1000 live births. (NDHS 2011). So, when the sensitized and committed health social mobilizers are mobilized the figure could be reduced with the increased community awareness, increased ANC service utilization and proper care of the newborn and timely referral for the treatment to the higher centre with the facility to manage the problems.
Proper care during pregnancy, delivery and after delivery is important for the health of both the mother and the baby. Access to proper medical attention and hygienic condition during delivery can reduce the complications and infections that may lead to death or serious illness for the mother and/or baby. Urban women are far more likely to benefit from skilled delivery care than rural women. A skilled provider assisted Sixty per cent of births to urban mothers, and 69% were delivered in a health facility, as compared with 47% and 44% respectively of births to rural women. Sixty-one per cent of births in hill zone were assisted by a skilled provider, compared with only 43% of those in the mountain zone (MoH, 2017). There is a sizeable disparity in maternity care by state; while skilled providers assisted 70% of birth. A large proportion of maternal and neonatal deaths occur during the first 48 hours after delivery. Thus, prompt postnatal care (PNC) for both the mother and child is important to treat any complication arising from the delivery, as well as to provide the mother with important information on how to care for herself and her child. Safe motherhood programmes and Reference Manual for Maternal and Neonatal Health Update 2072 recommends that all pregnant women should receive at least four antenatal visits and at least three postnatal visits after the delivery (MoH, 2017).
Poor sanitation and dirty water is another important cause of child mortality in Nepal. According to a report by the Centre of Environmental Action and Development, Nepal (CEAD, 2014), one-third child related deaths are due to water borne diseases. Diarrhea affects large proportion of under five children in Nepal; about 7,900 children die from diarrheal diseases caused by dirty water and poor sanitation. Other health related behaviours such as birth spacing, and breast-feeding practices have also contributed to increasing risk factor for child mortality.
Maternal mortality is a serious public health problem in Nepal as well as other developing countries. More than 80% of these deaths are preventable and caused due to lack of maternal health knowledge and socioeconomic conditions. Women who lack knowledge of family planning and who practice unsafe reproductive health have poor use of prenatal care. Providing information on prenatal care in simple language or through pictures which enable them to understand easily are important. Interventional approaches and policies should be put in place to make reliable prenatal care easily accessible to disadvantaged group at free or low cost. Specific community-based programs are needed in a developing country like Nepal. Authorities need to emphasize not only in implementing of interventional programs but also on keeping track of their success rates and drawbacks. Therefore, women’s level of education needs to be increased and women should be involved in health-related programs in the community, which may in turn help to empower them. Basic health education and a quality health service should be provided to all people to prevent morbidity, mortality, and disabilities of women.
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