Measuring Maternal Health

What is Maternal Health?

Maternal health is health at the time of pregnancy, childbirth or postpartum period. It is pleasant experience to women and families; however, some women die or develop some complications that affect quality of life. Some even develop maternal complications causing chronic morbidities such as obstetric fistula (it is the condition where there is hole between rectum and vagina or between urinary bladder and vagina and the women suffering with it, are ostracized and secluded from family and the society in many cases), dyspareunia (painful sexual intercourse), prolapse (the pelvic organ is prolapsed down from vagina, women having such condition are stigmatized in the society and women consider it as shameful condition and hides it instead of seeking medical help) and they might be stigmatized and ostracized from the society just because she doesn’t get appropriate intervention at the time of childbirth. Some might have normal childbirth and may not need any assistance but no pregnancy can be considered free of risk as complications can arise at any point of time so there should be availability of appropriate, affordable health care service for each pregnant woman.

How can we measure maternal health?

Maternal health can be measured with specific indicators.

We can use the various indicators to understand the status of anything in any group or population. These are also useful in measuring progress towards predefined objectives. Depending upon the type of indicator, Indicator provides information regarding a health outcome or management process. Indicators are the markers to understand our own position on the pathway to our goal. If we want to cover 1000 km, the covered distance at particular time is the indicator to have understanding of our own progress. To assess the status of maternal health we can use impact indicators, Process indicator and outcome indicator. Impact indicators provide information on the end result, but may not provide understanding into how the outcome was achieved. Process and outcome indicators provide insight into the program activities carried out to achieve the objectives.

Maternal health is measured using such multiple indicators. Those indicators can be broadly categorized as Impact indicator, Outcome Indicator and Process indicator. Impact indicator is the indicator, which reflects the final expected change in the status. It expresses how much programmes have brought a change in the health status.

Outcome and process indicators are used to measure access to and use of care, as well as quality of care. Outcome and process indicators are generally easier to measure than impact indicators. However, the scope of outcome and process indicators is limited in that they do not measure the event of primary importance: maternal mortality. Nevertheless, if we don’t have quality data of maternal deaths, and other required information, then these outcome and process indicators can also be utilized to evaluate maternal health status and programmes. The most recent NDHS 2011 too evaluated outcome and process indicators instead of maternal mortality.

Indicators	Example
Impact indicator	Maternal mortality rate/ratios, Life time risk of maternal death
Outcome Indicator and Process indicator	Proportion of Deliveries by skilled personnel, proportion of birth by site, Met need for essential obstetrics Referral rate

Why do we need the Indicator?

1. To find out whether the implemented programmed are effective or not

2. To find out progress

3. To decide resource allocation

4. To explore the barriers and challenges in achieving the goal or objectives

Impact indicator is commonly used for evaluation of maternal health status and to assess the effectiveness of the maternal health programmes.

1. Maternal mortality ratio (MMR): is the total number of maternal deaths per 100,000 live births. The MMR is calculated as follows:

WHO recommends including maternal deaths that occur within 42 days of the end of pregnancy. The numerator includes deaths due to direct obstetric complications of pregnancy, labor, and the puerperium and deaths from a previously existing condition that develops during or is aggravated by the pregnancy (Indirect obstetric deaths). Deaths, resulted from accidental or incidental causes, such as an automobile accident, are generally not included in the numerator.  This indicator is used to measure obstetric risk once a woman becomes pregnant and useful to gauge the progress in maternity services.

The maternal mortality ratio measures risk of maternal death once a woman becomes pregnant. This is especially useful to measure progress in maternity services.

2. Maternal Mortality rate: The maternal mortality rate is the maternal deaths per 1,000 women of reproductive age. The maternal mortality rate measures the risk of dying and also includes the likelihood of both becoming pregnant and dying the pregnancy or the puerperium. 

 

3. Lifetime risk of maternal death

This enumerates a woman’s probability of dying from maternal causes over her reproductive life span, usually given as 30-35 years. This measure is determined by the probability of becoming pregnant and the risk of death once pregnant.This is the life time risk of a girl reaching to the age of 15 years. If some region have higher fertility rate, then the lifetime risk also increases as the woman is exposed to risk multiple times in her reproductive age and if the fertility is less the lifetime risk of maternal death is less.

4. Case Fatality rate

The case fatality rate is the proportion of death of women with obstetric complications in a specific facility providing emergency obstetric care. The CFR is calculated as follows:

For example, if the department of obstetrics and gynecology receives 100 cases of hemorrhage, 50 cases of prolonged or obstructed labor, 100 cases of postpartum sepsis, 100 cases of complications of abortion, 50 cases of preeclampsia/eclampsia, 100 cases of ectopic pregnancy and 100 cases of ruptured uterus in one month. Two hundred women die of such complications during this duration of one month.

The CFR would be

200                

______ = 0.33

600

The case fatality rate is an indicator of the likelihood that a woman with an obstetric complication will survive after admission to the medical facility. CFR can be calculated for specific complications as well as in whole.

This measure will be affected by the quality and promptness of medical care provided, and the condition of the woman upon admission to the facility.

5. Proportionate maternal mortality

Proportionate mortality is a useful measure of the percentage of deaths among women of reproductive age that are due to pregnancy.

6. Cause specific proportionate maternal mortality rate: we can also enumerate cause specific proportionate maternal mortality rate.

7. Proportion of maternal morbidity: It can be estimated to measure effectiveness and efficiency of maternal health care program as well as burden of diseases. Maternal morbidity refers to any physical, mental illness caused by pregnancy or childbirth. Prevalence or incidence of maternal complications and sequelae: we can also estimate the prevalence or incidence of maternal complications to get scenario of maternal health and quality, efficiency of maternal health care services.

• Acute maternal morbidity
• Postpartum maternal morbidity and disabilities
• Chronic morbidity

Process and outcome indicators

These indicators give clear picture of maternal health service. We can also have understanding about how much we are investing on maternal health programme and how many are getting the appropriate services. Number of trained skilled birth attendants, number of birthing centers per population, Proportion of Deliveries by skilled personnel, proportion of birth by site, Met need for essential obstetrics, Referral rate are such indicators.

Some terminologies

Maternal Health Status in Nepal

Nepal has achieved significant progress in Maternal health demonstrated by decreasing maternal mortality ratio in Nepal. Maternal mortality ratio is the impact indicator of the maternal health programmes. It was possible due to prioritization of safe motherhood and newborn healthprogram of Nepal along with other multiple socioeconomic and political advances.

To analyze the progress of the maternal health in Nepal, Lets look into the maternal health indicators.

(Impact indicator: It includes maternal mortality ratio, maternal mortality rate, lifetime risk of maternal death etc.)

Trends of Maternal mortality ratio and major development in the field of maternal health in Nepal

The decrement in MMR from 790 to 580 from 1990 to 1995 could be result of National Health Policy 1991 that had prioritized on preventive health services including Family planning, safe motherhood.

OUTCOME AND PROCESS INDICATOR

Nepal demographic and health survey 2011, instead of impact indicator, measured outcome and process indicator, which is relatively easy to enumerate than maternal mortality rate and ratios. Outcome and Process indicators are also important to evaluate the maternal health programmes as these will directly impact the progress in maternal health.

Indicator	Current data	Source
Antenatal care (% Of women attended at least four times during pregnancy by any provider)	50.1	NDHS, 2011
Skilled attendance at birth (% of births attended by skill health staff)	36	NDHS, 2011
Anti-Retroviral for women (HIV- positive pregnant women to reduce mother to child transmission)	20.1	NDHS, 2011
Postnatal care for mothers (% of mother who received care within two days)	45	NDHS, 2011

Maternal Health Services in Nepal: All the maternal health Policies, strategies and programmes are directed to make family planning service, antenatal care, delivery care, Postnatal care efficient so that mothers receive required services, get proper diagnosis and proper intervention when necessary. Activities in safe motherhood programme of Nepal focuses on making those essential care available, accessible to every woman and family. 

1. Antenatal Care

Antenatal care services include:

• At least four antenatal check‐ups: first at 4th month, second at 6th month, third at 8^th month and fourth at 9th month of pregnancy;
• Monitor blood pressure, weight and fetal heart rate;
• Provide information, education and communication (IEC) and behavior change communication (BCC) for danger signs and care during pregnancy and timely referral to the appropriate health facilities;
• Birth preparedness and complication readiness (BPCR) for both normal and obstetric emergencies (delivery by skilled birth attendants, money, transportation and blood);
• Early detection and management of complications;
• Provision of tetanus toxoid (TT) immunization, iron and deworming tablets to all pregnant women and malaria prophylaxis where necessary

Nepal had a target to achieve 80 percent of women completing at least four antenatal care visits during their last pregnancy by 2015.

2. Delivery care

Delivery care services include:

• Skilled birth attendants at deliveries (either home‐based or facility‐based); however, our programmes has focused on facility based deliveries
• Early detection of complicated cases and management or referral after providing obstetric first aid by health worker to appropriate health facility where 24 hours emergency obstetric services are available;
• Obstetric first aid at home and/or HP/SHP if complications occur, using Emergency Obstetric Care Kit (EmOC kit);
• Identification and management of complications during delivery and referral to appropriate health facility as and when needed;
• Registration of births and maternal and neonatal deaths.
• Nepal has committed in achieving 60 percent deliveries by SBA BY 2015 (2071/72). Institutional delivery as percentage of expected pregnancies has been increasing trend from 44 to 50 percent from 2068/69 to 2070/71 to achieve targeted 60% institutional delivery by 2015 (NHSP II, 2010-2015).

3. Postnatal care

Postnatal care services include:

• Three postnatal visits: First visit within 24 hours of delivery, second visit on the third day and third visit on seventh day after delivery;
• Identification and management of mother's and newborn in complications of postnatal period and referral to appropriate health facility as and when needed;
• Promotion of exclusive breastfeeding;
• Personal hygiene and nutrition education, post‐natal vitamin A and iron supplementation for the mother;
• Immunization of newborns; and
• Post‐natal family planning counseling and services

4. Emergency Obstetric Care:

The SMNH long term plan (2006‐2017) has envisaged that by 2017, CEONC services will be available in 60 districts, 80 percent of PHCCs will provide BENOC services and 70 percent of HPs will provide delivery services. All women who needed obstetric complication should receive EmOC services and there should be universal coverage of EmOC.

C/S as a proportion of all live births has been found increasing as compared to last two consecutive years. In FY 2070/71, C/S as a proportion of all live births has increased by 2 percent reaching 8 percent of all live births. At population level 5‐15% of C/S as a proportion of all live births is accepted as minimum and maximum standard by the WHO.

Still, there are many challenges affecting accessibility, availability, affordability and sustainability of maternal health programmes as some of the programmes are driven by external fund. However, the government should be alert enough for its sustainability or alternatives. Our progress is satisfactory, but still number of women die with preventable causes so universal coverage of maternal health services and prioritization of safe motherhood in the health sector should be continued.

Sources:

1. DOHS. Annual Report 2070/2071

2. Nepal’s Quest for health. Plan, Policies and their implications.

3. WHO, UNICEF, UNFPA, World Bank Group, and United Nations Population Division Maternal Mortality Estimation Inter-Agency Group. Maternal Mortality in 1990-2015:Nepal.

National immunization Programme and EPI schedule of Nepal

National immunization Programme of Nepal

Child health programme of Nepal includes Immunization, Nutrition, CBIMCI and Newborn Care. National Immunization Programme (NIP) is the priority program of department of Health Services, MOHP, Nepal and is considered successful public health intervention of Nepal. Currently eleven antigens are provided through the routine immunization under National Immunization programme of Nepal. There should be at least seven contacts of children (At birth, 6,10,14 weeks, 9, 12, 15 months) to health center to fully immunize as per national immunization programme of Nepal.

World Health organization established a program called Expanded Program on Immunization (EPI) in 1974 and many countries started implementing EPI. Expanded program on Immunization (EPI) including BCG,and DPT vaccines in Nepal started in Nepal in 1979 in three districts. However, EPI including BCG, DPT, oral polio vaccine, and Measles was expanded to all 75 districts by 1989 only. Since then, government of Nepal is providing free immunization services to everyone regardless of their gender, socioeconomic strata without any discrimination. It is one of the accessible services of Nepal and has reached to the 97% population. Nepal is believed to be one of the countries recognized for the well functioning immunization system. This is also considered as the most cost effective public health programme.

EPI Schedule of Nepal

The Comprehensive Multi Year Plan (cYMP), which is a 5-year plan of action, governs the National Immunization Programme (NIP) of Nepal. NIP is also guided by NHSP II, which focuses on increasing access and utilization of essential health care services to reduce disparities and considers Immunization as a package of free essential health care services. The Child Health Division (CHD) of the Ministry of Health and Population leads all immunization related activities and each district is responsible for the immunization coverage of that particular district (Annual Report 2011).

Goal of CMYP (comprehensive multi year plan 2011-2016)

• To reduce child, mortality, morbidity and disability associated with vaccine preventable diseases

Objectives and Strategies of CMYP

1. Objective 1: Achieve and maintain at least 90% vaccination coverage for all antigens at national and district level by 2016

Key strategies:

• Increase access and utilization to vaccination by implementing (Reaching every district) RED strategies in every district 
• Enhance human resources capacity for immunization management
• Strengthen immunization monitoring system at all levels
• Strengthen communication, social mobilization, and advocacy activities
• Strengthen immunization services in the municipalities

2. Objective 2: Ensure access to vaccines of assured quality and with appropriate waste management

Key strategies:

•      Strengthen the vaccine management system at all levels

3. Objective 3: Achieve and maintain polio free status

Key strategies:

•       Achieve and maintain high immunity levels against Polio by strengthening routine immunization and conducting high quality national polio immunization campaigns.
•       Respond adequately and timely to outbreak of poliomyelitis with appropriate vaccine
•       Achieve and maintain certification standard AFP surveillance

4. Objective 4: Maintain maternal and neonatal tetanus elimination status

Key strategies:

•        Achieve and maintain at least >80% TT2+ coverage for pregnant women in every districts
•        Conduct Td follow up campaigns in high risk districts
•        Expand school based immunization program
•        Continue surveillance of NT

5. Objective 5: Initiate measles elimination

Key strategies:

• Achieve and sustain high population immunity to reduce measles incidence to elimination level
• Investigate all suspected measles like outbreaks with program response
• Use platform of measles elimination for Rubella / CRS control

·      Continue case-based measles surveillance

6. Objective 6: Accelerate control of vaccine-preventable diseases through introduction of new and underused vaccines

Key strategies:

• Introduction of new and under-used vaccines (rubella, pneumococcal, typhoid, rota) based on disease burden and financial sustainability

7. Objective 7: Strengthen and expand VPD surveillance

Key strategies:

• Expand VPD surveillance to include vaccine preventable diseases of public health concern.
• Strengthen and expand laboratory support for surveillance.

8. Objective 8: Continue to expand immunization beyond infancy

Key strategies:

• Consider for booster dose of currently used antigen based on evidence and protection of adult from potential VPDs.

The current National Immunization activities are guided by those strategies to meet the objectives set in comprehensive multi year plan of Nepal.

Achievement till this date

Immunization services are provided free of cost through EPI clinics in hosptials, other health centres, mobile and outreach clinics, Non governmental organizations, private clinics. The government supplies all vaccines and immunization related logistics to these private institutions free of cost. All vaccines under National Immunization Programme are given free of cost to those private clinics, Nursing homes.

Nepal has attained polio free status in 27th March 2014, sustained maternal and neonatal tetanus elimination since 2005, and Japanese encephalitis is in control status and conducting measles case based surveillance to meet the target of elimination by 2019 (Annual Report 2070/71).

In the fiscal year 2071/72, The national coverage of BCG is the highest of all antigens indicating almost 99% coverage, while DPT‐HepB‐Hib and OPV‐ 3 coverage are more than 91%. The measles/rubella vaccine coverage is 88% and Td2+ coverage (Td2 and Td2+) coverage is 75%. The JE coverage (31 districts) is 75%.

Click here for Vaccine type and storage

Sources:

Jos Vandelaer, Jeffrey Partridge, Bal Krishna Suvedi,. Process of neonatal tetanus elimination in Nepal. Journal of Public Health. 2009.

Suvedi BK. Immunisation programme of Nepal: an update. Kathmandu University Medical Journal. 2003. Vol. 2 No. 3, Issue 7.

DOHS. Annual Report 2071/72.

Women's work and associated risk

Work can be categorized into formal and informal/ paid and unpaid. Participation or non-participation in particular type of occupation perpetuates the one’s position in the society. This plays an important part in determining relative wealth, power and prestige of women and men. This also generates gender inequalities in the distribution of resources, benefits and responsibilities.

Traditionally, a woman is considered a homemaker and man, a breadwinner. Men were engaged in formal and paid work that made them always independent, leader, powerful and respectful relative to the women. However, with world wars and industrial revolution, women also started to engage in formal sector of employment. Education opportunities to women, mechanization, wide horizon of job perspectives, decreasing fertility have led to increased participation of women in the formal work in this century even in developing countries like Nepal.

Why women were left behind?

• Gender stereotypes: Women are believed to be physically, mentally weak, sensitive, caretaker and good homemaker whereas men are believed to be bold physically, mentally and were prepared to deal with affairs outside the house.
• Stage of Society (Agrarian Vs. Industrial): Society developed from agrarian stage; agriculture was principle source of subsistence and Men were considered major labour force then.
• Scientific Development: Innovations and technological advancement have changed the world around. The world is a global village now. The work that required much force, nowadays need just some skills due to the inventions of the machines, robots. But beforehand, women weren’t considered capable of doing hard work.
• Male dominance: Since the beginning of the society, male dominated the society, politics and other affairs. They made the law and guided the rules and regulations, norms in the society. They synthesized the societal rules preferring themselves.

Nevertheless, the workplace can be a setting where gender inequalities are both demonstrated and

sustained, with consequent impacts on health. Women make up about 42% of the estimated global working population.  According to World Bank estimates, from 1960 to 1997, women have increased their numbers in the global labour force by 126% (World Bank, 2001) and has been estimated that more and more women will be involved in both formal and informal works.

Where are they mainly employed?

·      Domestic help

·      Sexual trade

·      Massage parlor

·      Dance bar and restaurants

·      Agriculture

·      Shift works

·      Remaining at Mainstream employment

Their employment in such places put them at more hazards and insecurities even though they can earn hard cash to sustain their family and themselves.

What can happen in the work place due to gender based disparity?

Harassment especially sexual harassment

Disparity in payment and other facilities

Factors Influencing Health

There are five major determinants of health, i.e., factors, which promote or impair individual and community health. Genetic or biologic factors, such as age, sex, race, and genetic susceptibility to disease are innate and, at present, unchangeable. Environmental exposures, such as physical (sunlight), chemical (pollutants) and biologic (exposure to viruses/bacteria) also influence health. Behavior patterns, such as diet, physical activity, and sexual behavior, play a major role in the development of both infectious and chronic diseases. Access to medical care influences both development and outcome of disease, and individuals or communities with limited or difficult access to healthcare fare worse than those with easy access to healthcare. Last but not the least social circumstances are another challenging determinants of health. Socioeconomic status and class have  profound impact on health, as people living in poverty do not have the resources necessary to maintain their health.

Social circumstances maintain women’s low status in the society. Women become poor as they don’t earn or earn much less than men so they might not have access to health care and other utilities that boost one’s health.

Why does their involvement in work need attention?

They assume multiple role and carry out responsibilities but are always considered petty.
Though Women work as much as men, their work is not considered economically productive.
In most cases women work in the houses and they look after the household chores and effect of their work on their health has been understudied. 
The hazards and risk factors associated with work are understudied.
The workplace don’t implement gender based policies/ gender friendly provisions.
Women are less prioritized for the job with assumption that they will be overwhelmed with child bearing and rearing.
More likely to participate in part time job: that lack insurance coverage, other security, and allowances.

Impact of women's work on Health status

Stress

Strain in the Family

Probability of Sexual, physical, mental harassment

Time Constraint for self care and child care

Increased exposure to risk: physical, chemical, psychological, biological agents

Double burden of work

Conflict between partners, with other family members

Further Action and Recommendations

• Investment and Focus on education of girls so that they would get opportunities in formal sectors.
• Employment opportunities with prioritization and quota reservation
• Gender friendly policy at work place
• Gender based ergonomics: Equipment, tools and spaces used for paid labor have tended to be designed for men only.
• Gender based analysis in occupational health research
• Research should be gender sensitive and Interdisciplinary research with strong epidemiological, biological and social science components should be done since this is essential for the understanding of gender issues in occupational health