Namuna Rai from Dharan gave birth to a baby boy last month at the Paropkar Maternity Hospital in Kathmandu. At the time of delivery, she was very concerned as, she said, she barely visited health facilities during pregnancy.

"Until six months into the pregnancy, I could not visit any health facility. Thankfully, we are in good shape," Rai said, about herself and her infant.

Rai, 18, and her husband moved to Kathmandu from Dharan after their marriage last year. Soon her husband started working at a construction site to earn a living.

"I did not know my way around the city and my husband hardly got time off work to take me for check-ups," she said.

Since Rai was in the Capital, she could access the health facility at the time of delivery and she did not have to face complications even though she had missed her regular ante-natal check-ups.

Health experts say a pregnant woman must get examined at least four times to avoid the risk of maternal and child death, and risks are high if the woman is underage.

In Nepal, maternal mortality rate is still a cause for concern, as women in rural and far-flung areas still miss the antenatal and postnatal check-ups, while those in urban centres continue to face access barriers due to various reasons, like in Rai’s case financial constraints.

Dr Bhagwan Koirala, a consultant cardiac surgeon and former director of Tribhuvan University Teaching Hospital, says Nepal made good strides in the last 20 years when it came to reducing maternal mortality rate and even won international awards.

“But we are stuck now,” said Koirala in a recent interview with the Post. "We have hit a plateau."

According to the 2016 National Demographic Health Survey, the maternal mortality rate for Nepal is 239 per 100,000 live births for the seven-year period before the survey. The confidence interval for the 2016 maternal mortality rate ranges from 134 to 345 deaths per 100,000 live births.

Nepal reduced maternal mortality rate from 539 in 1996 to 239 in 2016 for which the country received the Millennium Development Goal award.

“What is worrisome is we successfully reduced maternal deaths by more than half in the war period, but we have not made any progress since,” said Dr Kiran Regmi, former secretary at the Ministry of Health and Population.

Maoists’ “people’s war” started in 1996 and ended in 2006. The country was mired in a political transition for another 10 years.

The success in improving maternal health was based on multiple factors—free delivery services, transport incentives, access to safe delivery services and the use of the oral drug misoprostol, distributed by female community health volunteers, for preventing postpartum haemorrhage during home births or on the way to a health facility.

The legalisation of abortion in 2002 also largely contributed to reducing the maternal mortality rate.

As part of its bid to ensure safe delivery, the government in recent years has also invested a lot in setting up birthing centres across the country—with an aim to establish at least one at each health post.

The number of birthing centres has increased but the quality of service has not improved, said Sudha Sharma, a former health secretary.

“With limited human resource and rising numbers of pregnant women visiting health posts—or birthing centres—they are forced to return home six to seven hours after childbirth,” said Sharma. “New mothers should be under observation for at least 24 hours. It’s difficult for women from far-flung areas to get timely care when they develop postpartum complications after returning home or on their way home.”

According to the Family Welfare Division, of the total number of maternal deaths, 24 percent occur during or after childbirth and 19 percent during the postnatal period.

Dr Punya Poudel, a focal person of ‘Safe Motherhood Program’ of the Division, said bringing women to health facilities before and after giving birth is a major challenge.

“Those who receive safe delivery service at health facilities usually do not seek postnatal care,” said Poudel.

Excessive bleeding, which is called postpartum hemorrhage, is one of the major reasons for death of mother after childbirth.

Similarly, high blood pressure, infection, unsafe abortion, pulmonary embolism (blood clot in lung), anemia and diabetes are other reasons behind the death of mother in postpartum period. According to the Division, 43 percent pregnant women are still giving birth at home, risking lives of both the mother and her newborn.

To address this, the government has been providing free institutional delivery service and cash incentives to those who visit health facilities for safe delivery services (Rs 3,800 in incentives, Rs 3,000 travel allowance and Rs 800 for receiving all four antenatal check-ups to people from the mountainous region; Rs 2,000-Rs 2,800 travel allowances and Rs 800 for four antenatal check-ups to the women of the hilly region, and Rs 1,000-Rs 1,800 travel allowances and Rs 800 for all four antenatal check-ups in the Tarai region).

But despite all these efforts, only 57 percent pregnant women receive free delivery services from health care facilities, according to the Family Welfare Division of the Department of Health Services.

According to the Division, Nepal’s commitment to reducing—and limiting—maternal mortality to 125 per 100,000 births by 2020 is impossible, as the number of maternal deaths has not seen a decline.

“There is a need to ensure access to health services for all,” said Sharma, the former health secretary. “One of our studies had found that birthing centres within a two-kilometre range were visited by all pregnant women, but the ones that were at a distance of five kilometres saw only 50 percent of the pregnant women.”

With maternal mortality rate now stuck at 239 for every 100,000 live births over the years, concerns from experts that Nepal has hit a plateau appear to be genuine.

And for the Sustainable Development Goals, the target is even more challenging: Nepal aims to reduce maternal mortality rate to 70 per 100,000 live births by 2030.

“Our focus should be on building comprehensive healthcare services,” said Koirala. “Maternal and neonatal mortality rates are not going to come down unless we improve our entire health care system.”