Nepal reduced its maternal mortality rate (MMR) from 539 per 100,000 live births in 1996 to 239 in 2016, which was hailed as a huge achievement. And for this, the country even received the Millennium Development Goals award. The country committed to further bringing the MMR down to 70 per 100,000 live births to meet the Sustainable Development Goals target by 2030.

However, the target seems impossible to achieve, as the number of deaths has not declined significantly since 2016.

The country has already missed its own 2020 target of reducing MMR to 125 per 100,000 live births. By 2022, Nepal has to reduce maternal deaths to 116 per 100,000 births to meet one of the Sustainable Development Goals.

Since 2006, Dr Mingmar Gyelgen Sherpa, a former director general of the Department of Health Services, has been providing ultrasound training to nurses serving in remote areas, at Solukhumbu Polytechnical Academy in Solukhumbu district. Hundreds of nurses have been trained by the Academy in the last 16 years. Trained nurses equipped with portable ultrasound machines visit pregnant women at their homes for examination. This has been helpful in saving many pregnant women.

In this context, the Post’s Arjun Poudel interviewed Sherpa, who is currently in Sudurpaschim Province to provide ultrasound training to staff nurses, about the challenges in reducing maternal deaths in Nepal.

Nepal has failed to meet its 2020 and 2022 targets on reducing maternal deaths. How difficult is it to meet the 2030 Sustainable Development Goals target?

At present, we are nowhere on track to meet the 2030 target, be it maternal health or child health. To meet the target, something effective needs to be done. We need micro-planning, its effective implementation, and a thorough review of the programmes. We need to identify the shortcomings at the earliest. We need to learn from past mistakes also.

For that, people in leadership positions should listen to experts' advice.

Do you mean that the existing government policies and programmes are not effective at reducing preventable maternal and child deaths?

Action speaks louder than words. Women in many parts of the country are dying during pregnancy, childbirth and in the postpartum period. This is the fact. And the facts tell us we are unable to prevent avoidable deaths of pregnant women and children. Efforts are essential for achieving something. For better results, something effective should be done. Our existing policies and programmes and the working style of government agencies will not help us achieve the targets.

Delivery services are free at state-run health facilities across the country. The government has decided to double antenatal care visits. Staff nurses are being hired to provide postnatal care at home for which allowances have been allotted. Do not these programmes work?

The fact is, despite all these, maternal and child mortality rates have not declined significantly. The question is not how many women give birth to their babies safely but how many women die during their pregnancy and childbirth and in the postpartum stage.

Hundreds of women are dying every year due to birth-related complications. Most of the maternal deaths are avoidable. The government not only provides allowances to pregnant women but also to health workers and the health facilities.

Has the allowance provision worked? No. Or else, maternal and child deaths should have declined. And such monetary allowances are encouraged by aid agencies. Nepali authorities blindly follow donors’ policies without questioning them.

If the government is certain that allowances are effective at preventing deaths, why aren’t they providing allowances for other conditions—Maybe they could offer Rs100 to diarrheal patients, Rs200 to those suffering from common cold, Rs300 to jaundice patients, and so on.

What are the flaws in the programmes aimed at avoiding preventable maternal and child deaths?

To prevent avoidable maternal and child deaths in the country, first we practised the sudeni [birth attendant] programme. Instead of reducing maternal mortality rate, the practice increased the deaths of women and children. After practising this for over 10 years, we stopped the programme on the recommendation of the World Health Organisation.

Then we practised the Maternal and Child Health Workers Programme for another 10 years. After the programme too failed to yield desired results, health workers under the programme were promoted to auxiliary nurse midwives (ANMs).

The ANMs too couldn't prevent maternal and child deaths. After running the programme for 10 years, we opted for the current “skilled birth attendant programme”. By imparting two to three months of training to staff nurses, authorities concerned have been trying to make progress in the maternal and child health sector. But this attempt too will turn futile. Staff nurses, who are trained for a few months, cannot prevent maternal and child deaths substantially.

Then what should have been done ?

Most developed countries including the United States and the United Kingdom have been providing midwifery services. Midwife is a health professional, who cares for mothers and newborns around childbirth. It is a three to four years university course. Health workers pursuing a career in midwifery are provided advanced training on the mother’s and child health since the beginning.

To reduce the maternal and child death rates, midwifery services should have started in our country also. But sadly we do not have any practicing midwives.

Is the government unaware of the best practices employed in many countries that have successfully reduced the maternal and child death rates?

In our country, political leadership keeps changing frequently. And it is not necessary that every minister should have expert knowledge. What is needed is people close to the political leadership must be knowledgeable, have willpower to bring change and listen to experts and implement their right suggestions.

Sadly, only those who can appease the leadership are hired as experts here.

Also, aid agencies provide support to half-baked programmes, which they know do not work. They seem to be more interested in spending the allocated funds and taking credits.

When the country is not producing midwives, how can we hire them? How many midwives are needed in Nepal and how long does it take to produce the required number?

The government should first develop and approve the curriculum for midwifery studies, allow universities to teach courses and then create midwife posts in the health service. We need around 10,000 midwives and it takes around 10 years to produce that number. Until then, authorities should promote hospital delivery.

As anything can happen at any time during pregnancy, and chances of death increase when pregnant women rely on birthing centers in villages. The Skilled Birth Attendant nurses serving at birthing centers cannot figure out the complications in advance, and this increases the risk of deaths.

Then what should be done?

Until we are able to recruit midwives, we should provide ultrasound training to the staff nurses currently serving in remote villages. Just give each of them a portable ultrasound machine, which costs around Rs400,000, and ask them to perform tests regularly. Many local governments in Sudurpaschim Province have invested in such machines. Ultrasound tests help figure out the problems, so that women with problems can be sent to health facilities that provide advanced care.

Don’t we need a huge budget to prepare and hire 10,000 midwives, and purchase thousands of portable ultrasound machines?

Every penny spent on health is a long-term investment because it saves lives. And it is the basic responsibility of the state to provide health care services for free. Healthy population is any nation’s biggest asset and key to prosperity.